Non-Emergency Transportation Provider Specific Policy ...

Non-Emergency Medical Transportation Provider Policy Manual

Non-Emergency Transportation
Provider Specific Policy
Revision Table

Effective Sections Description
Date of Revised
Revision Complete manual revision to reflect changes related to the
All MMIS and HIPAA compliance.
7/1/02 The revisions are necessary to: 1) Correct codes that were
incorrectly entered, 2) include additional codes in the “new
7/1/02 14.7 code” column, and 3) remove “RS” modifier on codes S0209
and S0215.
10/1/02 Entire Manual As of 10/1/02, DMAP utilized a broker system to provide ALL
Archived non-emergency transportation (including non-emergency
ambulance) to eligible Medicaid clients.

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Non-Emergency Medical Transportation
Provider Specific Policy Manual

Table of Contents Main Menu

1.0 Overview

1.1 General Information

2.0 Definitions

2.1 Non-Emergency Medical Transportation Services
2.2 Related Definitions

3.0 Limitations and Exclusions

3.1 Limitations
3.2 Exclusions

4.0 Prior Approval

4.1 Requirements

5.0 Reserved for Future Use
6.0 Provider Responsibilities

6.1 Participation Requirements

7.0 Vehicle Standards

7.1 Minimum Requirements

8.0 Transporting Mobility-Impaired Clients

8.1 Vehicle Standards

9.0 Transporting Children

9.1 Standards

10.0 Driver Standards

10.1 General Safety

11.0 Driver Qualifications

11.1 Standards

12.0 Operational Requirements

12.1 Service Policies
12.2 Personnel Policy

Non-Emergency Medical Transportation Provider Policy Manual

12.3 Equipment Policies
12.4 Vehicle Maintenance
12.5 Vehicle Modification

13.0 Reimbursement

13.1 Vehicle Other Than Taxi
13.2 Taxi Providers

14.0 Appendix A – Non-emergency Medical Transportation Reimbursement

14.1 Appendix A.1 - Transportation in Vehicle Other Than Ambulance Reimbursement by Base
Rate Plus Mileage

14.2 Appendix A.2 – Reimbursement by Base Rate Plus Mileage - Holidays
14.3 Appendix A.3 - Reimbursement by Mileage and Hour of Service
14.4 Appendix A.4 - Taxi Service
14.5 Appendix A.5 - Reimbursement by Assigned Rate
14.6 Appendix A.6 - Transportation Co-Pay
14.7 Appendix A.7 – Transportation Codes on and after 7/1/02

15.0 Appendix B – Transportation Scheduling Form

15.1 Instructions for Completing the Transportation Scheduling Form

16.0 Appendix C - Medicaid Transportation Provider’s Driver’s Log

Non-Emergency Medical Transportation Provider Policy Manual

Non-Emergency Medical Transportation Provider Policy
1.0 Overview

1.1 General Information

1.1.1 In accordance with Federal Regulation, 42 CFR 431.53, the Delaware Medical
Assistance Program (DMAP) will assure transportation for eligible Medicaid
clients who need to secure necessary medical care and who have no other
means of transportation. The DMAP is designed to assist eligible Medicaid
clients in obtaining medical care within the guidelines specified in this policy.

1.1.2 The DMAP defines non-emergency medical transportation services as
transportation to or from medical care for the purpose of receiving treatment
and/or medical evaluation. The DMAP will determine the transportation provider
to be in compliance with this policy as long as the transport is to or from a
medical service. Examples of medical services are found in the General Policy.

1.1.3 The DMAP will cover short-response taxi service provided by DelDOT certified
companies.

1.1.4 The DMAP covers transportation of a minor Medicaid client with an adult escort
OR transportation of an adult Medicaid client with a medically necessary escort.

1.1.4.1 The DMAP also covers transportation to the hospital for up to two caregivers of a
hospitalized Medicaid client.

1.1.5 The DMAP covers transportation for eligible Medicaid clients from the point of
pickup to the medical provider location or from the medical provider location to
the point of delivery.

1.1.6 The service will include all vehicles, drivers, dispatch, vehicle maintenance, fuel,
lubricants, and any and all other components necessary to provide a
transportation service for the needs of the DMAP client.

1.1.7 Refer to Prior Approval – Requirements section of this manual for special
transportation needs.

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2.0 Definitions

2.1 Non-Emergency Medical Transportation Services

2.1.1 Non-emergency medical transportation services are defined as transportation to
or from any medical service for the purpose of receiving treatment and/or medical
2.2 evaluation.

2.2.1 Related Definitions
2.2.2
The following definitions pertain to non-emergency medical transportation only.
2.2.3
2.2.4 Appropriate Method of Transportation is the least expensive mode of
2.2.5 transportation that best meets the physical and medical circumstances of a client
2.2.6 requiring transportation to a medical service.

2.2.7 Assistance is when a client must be physically helped from within or into a
building and/or from within or into the medical provider’s site. Without such
assistance, it would be unsafe or impossible for the client to reach the vehicle or
the medical provider’s site. The assistance is included as part of the
transportation rate and may not be billed separately.

Attendant is an employee of a transportation provider who in addition to the
driver is required to assist in the transport of the client due to his/her physical,
mental or developmental status. Attendant services are included as part of the
transportation rate and may not be billed separately.

Cancel Call is notification to the transportation provider, prior to the time the
vehicle is enroute to the pickup point, not to provide services to a client.

Caregiver is an individual responsible for the care of a hospitalized Medicaid
client and who must participate in the medical decision-making and/or receiving
instruction in the care of the client in preparation for discharge.

Escort is an interested individual that must accompany a client due to client’s
physical/mental/developmental capacity. Examples of an escort include, but are
not limited to, a parent, guardian, or an individual who assumes parental like
responsibility, or a child of a geriatric parent. The escort’s presence is required
to ensure that the client receives proper medical service/treatment. The escort
may not be employed by or provided by the transportation company delivering
the transport.

Holiday – Refer to Appendix A.2

Non-Emergency Medical Transportation Provider Policy Manual

2.2.8 Loaded Mileage is the distance traveled by a motor vehicle while transporting a
2.2.9 client from a pickup point to a drop-off point.
2.2.10
No Show is when a client fails to cancel a scheduled transportation service and
2.2.11 the transport arrives at the pick-up point.
2.2.12
2.2.13 Prior Authorization is the approval for a service by the DMAP or the DMAP’s
2.2.14 agent before the provider actually renders the service. In order to receive
2.2.15 reimbursement from the DMAP, a provider must comply with all prior
authorization requirements. The DMAP in its sole discretion determines what
2.2.16 information is necessary in order to approve a prior authorization request.

Provider Agreement is the signed written contractual agreement between the
DMAP and the provider of services.

Client is a person eligible for services through the DMAP.

Rideshare - A rideshare participant is a client who is able to share a ride with
another client because their route and time coincide.

Trip - Transporting an eligible client to or from a medical service. If the
transportation provider waits for the medical service to be delivered subsequent
transportation of the client is a continuation of the original trip.

Unloaded Mileage is the distance traveled by the motor vehicle to the point of
pickup of the passenger AND/OR from the point of drop-off of the passenger.
The transportation provider can only charge mileage when the passenger for
whom the claim is submitted is physically in the vehicle. Mileage cannot be
charged enroute to the pickup point or enroute from the drop-off.

Waiting Time is the time a vehicle is waiting at a medical provider’s facility, to
which the transportation provider transported the client, in order to transport the
client to another destination, during the same trip.

Non-Emergency Medical Transportation Provider Policy Manual

3.0 Limitations and Exclusions

3.1 Reimbursement for medical transportation will be made subject to the limitations
and exclusions that apply to these services. The limitation and exclusions are,
3.1.1 but not limited to:
3.1.2
3.1.3 Limitations

3.2 The DMAP reserves the right to make the determination as to which type of
transportation is the most appropriate for the client.
3.2.1
3.2.2 The DMAP may pay for only the least expensive appropriate method of
3.2.3 transportation, depending on the availability of the service and the physical and
3.2.4 medical circumstances of the patient (client).
3.2.5
3.2.6 The DMAP reserves the right to limit its payment of transportation to the nearest
appropriate provider of medical services when it has made a determination that
3.2.7 traveling further distances provides no medical benefit to the client.

Exclusions

The DMAP will not reimburse for services in which prior approval is required but
was not obtained.

The DMAP will not reimburse for services that are not medically necessary or
which are not provided in compliance with the provisions of the Program.

The DMAP will not reimburse for taxi service that is to/from on-going or recurring
services such as, but not limited to: Methadone Clinics, Community Mental
Health, physical, occupational, and speech therapy.

The DMAP will not reimburse for transportation provided by relatives or
individuals living in the same household with the client.

The DMAP will not reimburse for transportation provided in the client’s vehicle,
driven by the client or another person.

The DMAP will not provide transportation to a medical facility when the visit is for
the sole purpose of the client picking up a prescription or written prescription
order. However, if the client is returning from a physician, hospital or other
medical appointment and needs to stop to pick up a prescription, and if the stop
does not add significantly (i.e., one or two miles) to the transport, the DMAP
would consider this an approved service.

The DMAP will not reimburse non-emergency transportation providers for
transporting children to and from school. Transportation to and from school is

Non-Emergency Medical Transportation Provider Policy Manual

3.2.8 covered through the Children’s Services Cost Recovery Program which
3.2.9 reimburse school districts directly for qualified special needs children.

The DMAP will not reimburse non-emergency transportation providers for
transporting waiver clients to and from waiver services that are not medical in
nature. For example: day habilitation, life skill training.

The DMAP will not reimburse non-emergency transportation providers for
transporting Medicaid clients to meetings such as, but not limited to, Alcoholics
Anonymous (AA), Narcotics Anonymous (NA) and Gamblers Anonymous.

Non-Emergency Medical Transportation Provider Policy Manual

4.0 Prior Approval

4.1 Requirements

4.1.1 A non-emergency transportation provider must obtain prior approval from the
4.1.2 DMAP before providing the following transport services:
4.1.2.1
4.1.2.2 Any transportation by commercial bus, train, or air service;
4.1.3
Any transportation involving lodging and/or meals (reimbursement for meals is
4.1.4 limited to the amount authorized for State employees or less);

4.1.5 All transportation services outside the region (the region is D.C., PA, NJ and
MD).

Requests for approval must be submitted in writing and mailed or faxed to the
Medicaid Out-of-State Coordinator at:

Division of Social Services
Medicaid Unit, Lewis Building
P.O. Box 906
New Castle, DE 19720
FAX#: (302) 577-4899

If possible, approval must be obtained at least forty-eight hours before non-
emergency transportation services are rendered. When the client receives
health care services from more than one provider and requires approved
transportation to each, a separate prior approval must be obtained for
transportation to each health care provider.

Failure to secure approval from the Out-of-State Coordinator can result in non-
payment from the DMAP.

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5.0 Reserved for Future Use

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6.0 Provider Responsibilities

6.1 Participation Requirements

6.1.1 As a provider of non-emergency transportation services, it is the responsibility of
6.1.1.1 the provider to abide by the following policies and procedures of the DMAP. This
6.1.1.2 includes, but is not limited to:
6.1.1.3
6.1.1.4 The provider is responsible for maintaining current licenses, permits, or
certifications as required by all levels of government in Delaware for operation of
6.1.1.5 a vehicle(s). This includes, but is not limited to, vehicle license, driver’s license,
6.1.1.5.1 and business license.

The provider is responsible for maintaining complete and accurate records of
operational and administrative costs, and records that validate provider billing
and utilization of services. This material will be made available to authorized
representatives of the DMAP for review and audit.

The provider is responsible for maintaining all state-and/or locally required
insurance coverage for the protection of its fleet, clients, and personnel, and
upon request, shall furnish the DMAP with proof of this coverage.

The provider is responsible to provide door-to-door service and, when necessary,
the operator or attendant must provide assistance to clients in boarding and/or
alighting from the vehicle. An attendant is an employee of the transportation
provider who in addition to the driver is required to assist in the transport of the
client due to his/her physical, mental or developmental status. Providing
assistance is necessary when a client must be physically helped into or out of the
vehicle, residence, or the medical provider’s site. Without such assistance it
would be unsafe or impossible for the client to reach the destination. If it is the
policy of a transportation provider not to provide an attendant to assist client, it is
their responsibility to inform the client when completing the “Mobility Limitation”
line on the Scheduling Form (see Appendix B).

Providers must maintain such records as are necessary to fully disclose the
extent of services provided and when required furnish the DMAP and Federal or
State representatives with information regarding transportation services.
Records must include:

A Transportation Scheduling Form (see Appendix B) must be completed in its
entirety. Every line on the form must be completed with legible and accurate
information. A Scheduling Form is required for each date of service except for
those clients who have recurring medical appointments (Methadone Clinics,
Community Mental Health Clinics, Speech, Occupational, and Physical Therapy).
Clients with recurring appointments may have their Scheduling Form completed
on a monthly basis.

Non-Emergency Medical Transportation Provider Policy Manual

6.1.1.5.2 A completed driver’s log (Appendix C) must be completed in its entirety. Every
6.1.1.6 line on the form must be completed with legible and accurate information.
6.1.1.7
6.1.1.7.1 The provider is responsible for billing the DMAP only for actual loaded miles
provided.
6.1.1.7.2
The provider is responsible for arranging and providing transportation services
6.1.1.8 for DMAP clients as follows:
6.1.1.8.1
6.1.1.8.2 At the time of request for transportation the provider shall complete a
6.1.1.8.3 Transportation Scheduling Form (see Appendix B) to accurately reflect the
6.1.1.8.4 reason for the transport and to detail all information received from the client
6.1.1.9 regarding the transport. The completion of the Transportation Scheduling Form
will assist the transportation provider with a profile of the client and will help in
determining the client’s needs (if any).

Providers are required to verify client eligibility and other important client
information prior to rendering services by accessing one of the EVS options.
Instructions to accessing EVS is described in the EVS section of the billing
manual.

Obtain prior authorization, if required (see Section 4.0 Prior Approval of this
manual).

Schedule transportation and confirm the transport with the client.

Arrive at the location timely.

Always provide prompt and courteous service.

Submit a claim to the DAMP for only those services that were rendered.

The provider must maintain records to verify the services provided to Medicaid
clients as required in the General Policy and Provider Specific Policy.

Non-Emergency Medical Transportation Provider Policy Manual

7.0 Vehicle Standards

7.1 Minimum Requirements

7.1.1 Client safety is of primary importance during operation of vehicles utilized by
enrolled non-emergency transportation providers. The DMAP places particular
7.1.1.1 emphasis on the safety of the vehicles transporting Medicaid clients. Providers
7.1.1.2 of non-emergency transportation services must adhere to the following standards
and must ensure that:
7.1.1.3
7.1.1.4 A basic first aid kit is on each vehicle operated by DMAP providers.
7.1.1.5
7.1.1.6 A regulation size Class B chemical type fire extinguisher is on each vehicle.
7.1.1.7 Extinguisher must have a visible gauge or inspection tag reflecting annual
7.1.1.8 inspections and be placed in easy reach of the driver. The extinguisher must be
7.1.1.9 mounted in a bracket located in the driver’s compartment and be readily
7.1.1.10 accessible to the driver and passenger(s). The extinguisher’s pressure gauge
must be easily read without moving the extinguisher from its mounted position.
The operating mechanism shall be sealed with a type of seal that will not
interfere with the use of the fire extinguisher.

Seat belts and/or shoulder straps are installed in all vehicles.

Passenger occupancy for adults will not exceed the vehicle manufacturer’s
approved seating occupancy.

Vehicle interior and exterior will be free of hazardous debris or unsecured items.

Interior vehicle equipment will be secured at all times.

Vehicles shall be operated within manufacturer’s safe operating standards at all
times.

Vehicles shall display company identification when transporting DMAP clients.

Transportation services are rendered in vehicles that are maintained and kept in
good condition at all times.

A Certificate of Inspection issued by State of Delaware Motor Vehicles is required
to be displayed in the upper right hand side of the vehicle windshield.

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8.0 Transporting Mobility-Impaired Clients

8.1 Vehicle Standards

8.1.1 In addition to the vehicle standards previously mentioned, providers of non-
emergency transportation services who transport mobility-impaired clients must
8.1.1.1 provide the following:

8.1.1.2 Safe physical arrangements must be available for transportation of clients in
8.1.1.2.1 wheelchairs. The wheelchair must be secured to the vehicle at all times while
8.1.1.2.2 the vehicle is in motion.

Vehicles are handicap accessible, for example:

Ramps or wheelchair lifts must be available to provide easy access for a
wheelchair to enter and exit the vehicle; and

Doors of the vehicle must be wide enough to accommodate a wheelchair.

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9.0 Transporting Children

9.1 Standards

9.1.1 The following are additional policies for non-emergency transportation providers
9.1.1.1 who transport children:

9.1.1.2 An approved infant or child car seat or other specially adapted seating
appropriate to age and size of child must be utilized for transporting children.
9.1.1.3 The provider must exercise reasonable care that its infant or child car seats or
other specially adapted seating are safe.

The provider must assume responsibility for children transported without an
escort from time and place of pickup until delivered to parents, guardians or
responsible persons designated by parents or guardians.

Passenger windows will not be opened more than 50% when children are in
transport.

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10.0 Driver Standards

10.1 General Safety

10.1.1 Driver’s must be qualified by the minimum standards listed below as applicable:
10.1.1.1
The driver must refuse to operate the vehicle as long as any occupant is not
10.1.1.2 wearing a seat belt and/or a shoulder strap as required by Delaware law.
10.1.1.3 Passengers must wear a seat belt at all times with only one passenger per belt
10.1.1.4 where applicable. For children, see “Transporting Children” section of this
10.1.1.5 manual.

The driver must insist that all passengers be seated while the vehicle is in
motion.

The driver must park or stop the vehicle so passengers will not have to cross the
street to get to their destination or pickup point.

The driver must not permit smoking by passenger. The driver is also expected to
refrain from smoking while transporting DMAP clients.

The driver must not leave passengers who are unable to care for themselves
unattended in the vehicle.

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11.0 Driver Qualifications

11.1 Standards

11.1.1 Enrolled transportation providers who employ drivers and/or sub-contract with
11.1.2 drivers are responsible for the following driver qualifications.
11.1.2.1
Drivers (employed or sub-contracted) must be qualified by the standards listed
11.1.2.2 below (as applicable):

11.1.2.3 Drivers (employed or sub-contracted) must possess a current state license and
appropriate training. All drivers who transport clients in vehicles designed to
11.1.2.4 carry sixteen or more passengers including the driver, are required to have a
Class C driver’s license and adhere to the Delaware transportation code. The
11.1.2.5 capacity of the vehicle not the number of persons carried is the controlling factor.
11.1.2.6
Drivers (employed or sub-contracted) must have a pre-employment health
screening and a physical examination by a physician within six weeks of initial
employment or date of assignment to a driver’s position, with an annual review of
health status. Providers must use all appropriate means to assure that drivers
(employed or sub-contracted) are drug and alcohol free while transporting DMAP
clients.

Valid documentation of a driver’s (employed or sub-contracted) previous driving
record as recorded by Division of Motor Vehicle (DMV) must be obtained prior to
employment to assist in assuring that the applicant has a safe and competent
driving history. For three years prior to transporting Medicaid client, driver
(employed or sub-contracted) must not have D.U.I. (driving under the influence)
convictions or license revocation for D.U.I., or must not have three moving traffic
violations on his/her driving record. Valid documentation of driving record must
be obtained semi-annually thereafter or as necessary to assure driver
qualifications.

Drivers must receive training in the operation of all vehicle equipment, first aid,
CPR, emergency exits, fire extinguishers, wheelchair lifts, lockdowns, etc. This
certification must include training in passenger handling techniques, e.g.,
wheelchair movement and securement, boarding assistance, etc. Training must
also be given on patient confidentiality. Documentation of this training must be
kept in the provider’s files with proof of annual review.

All drivers (employed or sub-contracted) must complete training such as
defensive driving within six months of initial employment with a review as set by
the State of Delaware Safety Council.

Drivers (employed or sub-contracted must maintain a professional manner with
DMAP clients at all times.

Non-Emergency Medical Transportation Provider Policy Manual

11.1.2.7 At the time transportation services are rendered, drivers (employed or sub-
contracted) must present a valid “provider issued” identification to DMAP
passenger. A current picture of the driver must appear on the identification.

Non-Emergency Medical Transportation Provider Policy Manual

12.0 Operational Requirements

12.1 Providers must maintain office records that address the operational requirements
listed below:
12.1.1
12.1.2 Service Policies
12.1.3
12.1.4 Hours/days of service
12.1.5
12.1.6 Booking/dispatch procedures
12.1.7
12.1.8 Conditions for denial of service
12.1.9
12.1.10 Complaint procedures
12.1.11
12.1.12 Incident reports

12.2 Waiting time provisions

12.2.1 Attendant/escort provisions

12.2.2 Miscellaneous operating regulations (e.g., smoking aboard vehicles)

12.3 Entering client homes

12.3.1 Stopping enroute for client’s convenience

Emergency procedures

Passenger handling (wheelchair, stretcher, number of attendants, seat belts,
weight restrictions, etc.)

Personnel Policy

Discipline procedures for safety violations, passenger mishandling and training
programs.

Provider shall maintain and enforce policy regarding employee drug and alcohol
use.

Equipment Policies

Specifications (vehicle type, auxiliary equipment)

Non-Emergency Medical Transportation Provider Policy Manual

12.3.2 Maintenance procedures
12.3.3
Replacement policy
12.4
Vehicle Maintenance
12.4.1
12.4.2 Maintenance records must be kept on all vehicles.
12.4.3
Vehicle maintenance and safety checks must be done monthly.
12.5
Maintenance and records must comply with Delaware Department of Motor
12.5.1 Vehicle (DMV) standards and inspections.

Vehicle Modification

Providers must have documentation of vehicles modified to adapt to alternate
modes of service, e.g., passenger van converted to non-emergency ambulance,
wheelchair lifts added, etc., and remain within the codes and regulations of the
State of Delaware’s DMV.

Non-Emergency Medical Transportation Provider Policy Manual

13.0 Reimbursement

13.1 Vehicle Other Than Taxi

13.1.1 Non-emergency medical transportation providers are reimbursed a regional base
rate plus a universal rate per mile. Rates will be reviewed annually. Regions are
13.1.2 defined as the three counties in the State of Delaware.

13.1.3 Escorts, when needed, and rideshare participants will each be reimbursed the
13.1.4 regional base rate. Mileage will be reimbursed only for the client located the
most distance from the service provider.
13.1.5
The DMAP will pay a differential rate added to the base rate for service provided
13.2 between 6 PM and 6 AM weekdays and 24 hours on the weekends and holidays.

13.2.1 The DMAP will pay a differential rate for transportation service provided in a
13.2.2 vehicle equipped with a wheelchair lift and occupied by a client that is non-
ambulatory.

Reimbursement is full and represents all vehicles, drivers, dispatch, vehicle
maintenance, fuel, lubricants, and all operational and administrative costs
necessary to provide medical transportation services.

Taxi Providers

Non-emergency medical transportation by taxi is reimbursed at the metered rate
for a trip.

Reimbursement is full and represents all vehicles, drivers, dispatch, vehicle
maintenance, fuel, lubricants and all operational and administrative cost
necessary to provide medical transportation services.

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Transportation in Vehicle Other Than Ambulance

Reimbursement by Base Rate Plus Mileage

14.0 Appendix A – Non-emergency Medical Transportation
Reimbursement

14.1 Appendix A.1 - Transportation in Vehicle Other Than Ambulance
Reimbursement by Base Rate Plus Mileage

When billing the DMAP for services provided prior to 7/1/02 Non-Emergency Transportation
Providers shall use the codes and following instructions given in Appendices A.1 and A.2– A.6.
These codes and instructions cannot be used for billing the DMAP for services provided on and
after 7/1/02

When billing the DMAP for transportation in a vehicle other than an ambulance, the provider
must have a provider number ending in “15” with a specialty of van services (T6).

General

Provider is required to bill all transportation services for a single day on a single claim line. If a
single claim line spans more than one day, it will be denied. However, the dates of service of
the entire claim may span more than one day.

Provider must bill both base rate and mileage for the transportation of an individual responsible
for the care of a hospitalized Medicaid client using the Medicaid ID number of the hospitalized
client.

Base Rate

The following Level III HCPCS procedure codes must be used to bill base rate services for
dates of service prior to 7/1/02. See Appendix A.2 for the list of holidays.

Code Description

YY520 Transportation in vehicle other than ambulance, base rate, for service 6 AM
to 6 PM weekdays, per trip
YY523 Transportation in vehicle other than ambulance, base rate, for service 6 PM
to 6 AM weekdays and 24 hours on the weekends and holidays, per trip

Base Rate Modifiers
The following modifiers may be used with YY520 and YY523.

Code Description

Y1 Transportation of a minor Medicaid client with an adult escort OR
transportation of an adult Medicaid client with a medically necessary
Y2 escort OR transportation of a second individual responsible for the care of
a hospitalized Medicaid client to the hospital
Transportation of a non-ambulatory Medicaid client with a medically
necessary escort in a wheelchair accessible van

Non-Emergency Medical Transportation Provider Policy Manual

Code Description

Y3 Transportation of a non-ambulatory Medicaid client in a wheelchair
accessible van

Base Rate/Modifier Billing

A trip is defined as transporting a client to or from a medical service. If the transportation
provider waits for the medical service to be delivered subsequent transportation of the client is a
continuation of the original trip and a second base rate is not billable.

Provider will bill a base rate with no modifier when transporting an ambulatory adult Medicaid
client with no medically necessary escort.

Provider will also bill a base rate with no modifier when transporting an individual responsible for
the care of a hospitalized Medicaid client to the hospital. (This must be billed using the
Medicaid ID number of the hospitalized client.)

Provider may bill ONLY one modifier per base rate.

Provider must submit ONLY one claim line per base rate/modifier combination per day. The
units billed must reflect the total number of trips made per base rate/modifier combination per
day. The charge must reflect the total charge per base rate/modifier combination per day.

If more than four trips are made on a single day, provider must submit the claim via paper and a
copy of the Transportation Scheduling Form for each trip must be attached that clearly justifies
multiple trips.

All base rates for one individual day must be on the same line of the claim form unless different
modifiers are required. If different modifiers are required, provider must submit one claim line
per day for each base rate/modifier combination. The claim must be submitted via paper and a
copy of the Transportation Scheduling Form for each trip must be attached that clearly justifies
different modifiers.

Base Rate Remittance Advice (RA) Conversion

The system may convert YY520 or YY523 into a payment procedure code because the provider
is reimbursed according the client’s county of residence.

Provider bills: If the client lives If the client lives If the client lives
in Sussex in Kent County, in New Castle
YY520 County or any the code on the County, the code
YY523 out-of-state RA will be: on the RA will
location, the be:
code on the RA YY521
will be: YY524 YY522
YY525
YY520
YY523

Regardless of what procedure code is reflected on the RA, the provider should always bill the
base rate using either YY520 or YY523.

Non-Emergency Medical Transportation Provider Policy Manual

Mileage

The following Level III HCPCS procedure code must be used to bill mileage for dates of service
prior to 7/1/02. See Appendix A.2 for the list of holidays.

Code Description

YY526 Transportation in vehicle other than ambulance, each mile, per trip

Mileage Modifiers
The following modifiers must be used, if applicable, with YY526.

Modifier Description

X1 Return trip
X2 Second trip, same day, outbound
X3 Second trip, same day, return

Mileage Billing

Mileage for each trip must be billed on one line of the claim form. Subsequent trips on the same
day must be billed on separate lines of the claim form with the appropriate modifier.

Any billings for mileage that exceeds 300 miles per trip must be submitted via paper and a copy
of the Transportation Scheduling Form must be attached that clearly justifies the mileage billed.

In billing mileage for rideshare occupants, total mileage billed for all individual occupants must
equal the actual vehicle mileage from the initial pick-up point to the final drop-off point for all
rideshare occupants.

Example 1: If Ms. A is picked up first and Mr. B is picked up at a second location and
both have appointments at the same destination, provider must bill a base
rate and total mileage for Ms. A and a base rate only for Mr. B.

Example 2: If Ms. A is picked up first and Mr. B is picked up at a second location and
Ms. A is dropped off first and Mr. B is dropped off at a second but
different location, provider must bill a base rate plus mileage to Ms. A’s
destination under Ms. A’s Medicaid ID number and a base rate plus
mileage from Ms. A’s destination to Mr. B’s destination under Mr. B’s
Medicaid ID number. Thereby the total mileage billed for both Ms. A and
Mr. B equal the actual vehicle mileage from Ms. A’s initial pick-up point to
Mr. B’s final drop off point.

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14.2 Appendix A.2 – Reimbursement by Base Rate Plus Mileage -
Holidays

Providers may bill procedure code YY523 for service rendered on the following
holidays:

• New Year’s Day

• Good Friday

• Memorial Day

• Independence Day

• Labor Day

• Thanksgiving Day

• Christmas Day

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14.3 Appendix A.3 - Reimbursement by Mileage and Hour of Service

When billing the DMAP for transportation in a vehicle other than an ambulance, the provider
must have a provider number ending in “15” with a specialty of van services (T6).

Mileage Codes

The following Level III HCPCS procedure codes must be used to bill mileage for dates of
service prior to 7/1/02. See Appendix A.2 for the list of holidays.

Code Description

YY502 Transportation in vehicle other than ambulance, each mile, 1 through 20
YY503 miles for service 6:00 AM to 6:00 PM, Monday through Friday (Definition
YY504 change effective 08/15/94)
YY515 Transportation in vehicle other than ambulance, each mile, 21 through
YY516 149 miles for service 6:00 AM to 6:00 PM, Monday through Friday
YY517 (Definition change effective 08/15/94)
Transportation in vehicle other than ambulance, each mile, 150 miles and
over for service 6:00 AM to 6:00 PM, Monday through Friday (Definition
change effective 08/15/94)
Transportation in vehicle other than ambulance, each mile, 1 through 20
miles for service 6:00 PM to 6:00 AM on Monday through Friday and/or
6:00 AM on Saturday through 6:00 AM on Monday (effective 08/15/94)
Transportation in vehicle other ambulance, each mile, 21 through 149
miles for service 6:00 PM to 6:00 AM on Monday through Friday and/or
6:00 AM on Saturday through 6:00 AM on Monday (effective 08/15/94)
Transportation in vehicle other than ambulance, each mile, 150 miles and
over for service 6:00 PM to 6:00 AM on Monday through Friday and/or
6:00 AM on Saturday through 6:00 AM Monday (effective 08/15/94)

Mileage Modifier

The following modifier may be used with YY502-YY504 and YY515-YY517.

Modifier Description

Y1 Transportation of a minor Medicaid client with an adult escort OR
transportation of an adult Medicaid client with a medically necessary
escort OR transportation of a second individual responsible for the care of
a hospitalized Medicaid client to the hospital

Mileage Billing

Total daily mileage for each client for each service time period must be added together and
reported under the appropriate coding series of YY502-YY504 or YY515-YY517.

Provider will bill mileage with no modifier when transporting an ambulatory adult Medicaid client
with no medically necessary escort.

Provider will also bill mileage with no modifier when transporting an individual responsible for
the care of a hospitalized Medicaid client to the hospital. (This must be billed using the
Medicaid ID number of the hospitalized client.)

Non-Emergency Medical Transportation Provider Policy Manual

Provider must submit ONLY one claim line per code/modifier combination per day.

If different modifiers are required, provider must submit one claim line per day for each
code/modifier combination. The billing must be submitted via paper and a copy of the
Transportation Scheduling Form for each trip must be attached that clearly justifies the
circumstances.

Non-Emergency Medical Transportation Provider Policy Manual

14.4 Appendix A.4 - Taxi Service

When billing the DMAP for taxi service, the provider must have a provider number ending in “15”
with a specialty of travel/accommodations (T7).

Code
The following Level III HCPCS procedure code must be used to bill taxi services.

Code Description

YY518 Transportation - Taxi Service – metered rate

Modifier
The following modifiers must be used, if applicable, with YY518.

Modifier Description

X1 Return trip
X2 Second trip, same day, outbound
X3 Second trip, same day, return

Billing

Taxi service is intended to provide demand responsive, non-recurring transportation. The
DMAP will not reimburse taxi service that is to/from on-going or pre-scheduled services such as,
but not limited to: Methadone Clinics, Community Mental health, physical, occupational, and
speech therapy.

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14.5 Appendix A.5 - Reimbursement by Assigned Rate

When billing the DMAP for transportation in a vehicle other than an ambulance, the provider
must have a provider number ending in “15” with a specialty of van services (T6).

Code Description

YY505 Transportation in vehicle other than ambulance, by assigned rate, per
round trip
YY519 Transportation in vehicle other than ambulance by assigned rate - per one
way trip

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14.6 Appendix A.6 - Transportation Co-Pay

When billing the DMAP for transportation in a vehicle other than an ambulance, the provider
must have a provider number ending in “15”.

Code Description

WW104 Transportation Co-Pay

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14.7 Appendix A.7 – Transportation Codes on and after 7/1/02

When billing the DMAP for dates of service on and after 7/1/02, the non-emergency
transportation provider shall use the HCPCS codes listed in the “New Code” column below.

Old New Code Description of New Code Modifier
Code
A0110 Non-emergency transportation None
YY505 A0427 and bus, intra-or-interstate carrier None
YY506 Ambulance service, advanced life
A0429 support, emergency transport, None
YY507 level 1 (ALS)
A0380 Ambulance service, basic life None
YY509 A0390 support, emergency transport None
A0426 (BLS) None
YY510 Basic life support (BLS) mileage
A0428 (per mile) None
YY511 Advanced life support (ALS)
YY512 A0380 mileage (per mile) None
YY513 A0390 Ambulance service, advanced life None
YY514 A0424+PA support, non-emergency None
A0090+PA transport, level 1 (ALS) None
YY518 Ambulance service, basic life
YY519 A0225 support, non-emergency None
YY520 transport (BLS)
A0380 Basic life support (BLS) mileage None
A0390 (per mile) None
A0100 Advanced life support (ALS) None
A0110 mileage (per mile) None
T2003 Extra ambulance attendant, ALS None
A0130 or BLS (requires medical review) None
Non-emergency transportation;
per mile-volunteer, interested
individual, neighbor
Ambulance service, neonatal
transport, base rate, emergency
transport, one way
Basic life support (BLS) mileage
(per mile)
Advanced life support (ALS)
mileage (per mile)
Non-emergency transportation;
taxi, intra city
Non-emergency transportation
and bus, intra-or-interstate carrier
Non-emergency transportation;
encounter/trip
Non-emergency transportation;
wheelchair van

Non-Emergency Medical Transportation Provider Policy Manual

Old New Code Description of New Code Modifier
Code
T2003 Non-emergency transportation; None
YY521 encounter/trip
A0130 Non-emergency transportation; None
YY522 wheelchair van
T2003 Non-emergency transportation; None
YY523 encounter/trip
A0130 Non-emergency transportation; None
YY524 wheelchair van
T2003+ Non-emergency transportation; RS- (if applicable) indicates after
YY525 Modifier* encounter/trip hours/holidays/weekends
A0130+ Non-emergency transportation; RS- (if applicable) indicates after
YY526 Modifier* wheelchair van hours/holidays/weekends
T2003+ Non-emergency transportation; RS- (if applicable) indicates after
1010H Modifier* encounter/trip hours/holidays/weekends
A0130+ Non-emergency transportation; RS- (if applicable) indicates after
Modifier* wheelchair van hours/holidays/weekends
T2003+ Non-emergency transportation; RS- (if applicable) indicates after
Modifier* encounter/trip hours/holidays/weekends
A0130+ Non-emergency transportation; RS- (if applicable) indicates after
Modifier* wheelchair van hours/holidays/weekends
S0209 Wheelchair van, mileage, per None
mile
S0215 Non-emergency transportation; None
mileage
T2003+ Non-emergency transportation; TL-Early Intervention Family
Modifier* encounter/trip Services Plan (IFSP)
RS-(if applicable) indicates after
S0215+ Non-emergency transportation; hours/holidays/weekends
Modifier* mileage TL-Early Intervention Family
Services Plan (IFSP)
A0130+ Non-emergency transportation;
Modifier* wheelchair van TL-Early Intervention Family
Services Plan (IFSP)
S0209+ Wheelchair van, mileage, per RS-(if applicable) indicates after
Modifier* mile hours/holidays/weekends
TL-Early Intervention Family
1011H T2003+ Non-emergency transportation; Services Plan (IFSP)
Modifier* encounter/trip
TL-Early Intervention Family
S0215+ Non-emergency transportation; Services Plan (IFSP)
Modifier* mileage RS-Residence/scene of accident
or acute event
A0130+ Non-emergency transportation; TL-Early Intervention Family
Modifier* wheelchair van Services Plan (IFSP)

TL-Early Intervention Family
Services Plan (IFSP)

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Old New Code Description of New Code Modifier
Code
RS-(if applicable) indicates after
S0209+ Wheelchair van, mileage, per hours/holidays/weekends
Modifier* mile TL-Early Intervention Family
Services Plan (IFSP)
1012H T2003+ Non-emergency transportation;
Modifier* encounter/trip TL-Early Intervention Family
Services Plan (IFSP)
S0215+ Non-emergency transportation; RS-(if applicable) indicates after
Modifier* mileage hours/holidays/weekends
TL-Early Intervention Family
A0130+ Non-emergency transportation; Services Plan (IFSP)
Modifier* wheelchair van
TL-Early Intervention Family
S0209+ Wheelchair van, mileage, per Services Plan (IFSP)
Modifier* mile RS-(if applicable) indicates after
hours/holidays/weekends
TL-Early Intervention Family
Services Plan (IFSP)

* A modifier of TL and, if applicable, RS must be used when billing for after hour transports and
24 hours on weekend/holiday transports. Failure to use the modifier will result in improper
payment.

New Code Description

T2001 Non-emergency transportation, patient
attendant/escort

Code T2001 replaces the Y1 modifier previously used to report the use of an escort. Providers
may only bill code T2001 when billing code T2003 or A0130. Code T2001 is not to be used to
bill for attendants employed by the transportation provider.

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Transportation Scheduling Form

15.0 Appendix B – Transportation Scheduling Form

DATE: ________________
NAME: ____________________________________DOB: ___________MEDICAID#________________
ADDRESS: __________________________________________________________________________
____________________________________________________________________________________
DIRECTIONS: ________________________________________________________________________
REASON FOR
APPOINTMENT: _____________________________________________________________________
APPOINTMENT DATE: __________________________APPOINTMENT TIME: ___________________
PROVIDER’S NAME: _________________________________________________________________
PROVIDER’S PHONE #: ________________________
PROVIDER’S ADDRESS: ______________________________________________________________
___________________________________________________________________________________
MOBILITY LIMITATIONS: ______________________________________________________________
ATTENDANT NEEDED, OR ESCORT/PERSON(S) RESPONSIBLE FOR THE CARE OF A
HOSPITALIZED MEDICAID CLIENT BEING TRANSPORTED: _______________________________
PICKUP ODOM. RDG: ____________DELIVER ODOM. RDG: _____________MILES: ____________
PICKUP ODOM. RDG: ____________DELIVER ODOM. RDG: _____________MILES: ____________
CALL TAKER: ______________________________________
DRIVER: _________________________________________VEHICLE #: ________________

CALLED CLIENT WITH APPROXIMATE PICKUP TIME: DATE: ______________TIME:
____________
COMMENTS:_________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

CLIENT’S SIGNATURE: ________________________________________DATE: __________________

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