Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 140 - MEDICAL PAYMENT › Subpart L - UNAUTHORIZED USE OF MEDICAL ASSISTANCE › Table A - Criteria for Non-Emergency Ambulance Transportation

Current through Register Vol. 48, No. 28, July 12, 2024
a) To be eligible for non-emergency ambulance
				transportation, all other means of transportation, including taxi, wheelchair
				van, stretcher van or private automobile, must be contraindicated by the
				Department, a contracted MCO or their transportation broker.
b) In addition to adherence to the criteria
				in subsection (a), at least one of the following criteria shall be met. The
				criteria selected shall be supported by the patient's diagnosis, condition or
				treatment, as documented in the patient's medical record, and shall establish
				the need for non-emergency ambulance transportation service. Non-emergency
				ambulance transportation service will only be approved when clinical
				observation or treatment, as set forth in the criteria in this subsection (b),
				are medically necessary at the transferring facility and during transport, and
				are expected to be medically necessary at the destination. Examples for each
				criteria are provided for guidance, but are not intended to be an all-inclusive
				or an all exclusive list.
1)
Isolation
				Precautions.
A patient who has a diagnosed or suspected communicable
				disease or hazardous material exposure, who must be isolated from the public,
				or whose medical condition must be protected from public exposure, and for whom
				there is an order for isolation precautions.
EXAMPLE - Inclusion: This criterion includes a patient who
				  has a condition of methicillin-resistant Staphylococcus aureus (MRSA)
				  infection, who is currently undergoing treatment for the infectious condition
				  and who continues to have symptoms, such as cough, drainage or fever.
EXAMPLE - Inclusion: A patient with a dangerous communicable
				  disease that has the potential to cause an epidemic or threaten serious illness
				  or death to others if not controlled.
EXAMPLE - Inclusion: This includes a patient when "contact
				  isolation" is ordered for Clostridium difficile diarrhea, often called C.
				  difficile.
EXAMPLE - Exclusion: This criterion does not include a
				  patient who has a history of MRSA or C. difficile, or has been treated for MRSA
				  or C. difficile and is no longer symptomatic.
EXAMPLE - Exclusion: This criterion does not include a
				  patient with surgical drainage complications for which wound care precautions
				  are ordered, unless the patient's surgical complication includes a draining
				  wound that saturates a dressing and requires that the patient be isolated from
				  the public.
EXAMPLE - Exclusion: This criterion does not include a
				  patient who has a surgical dressing, ostomy, G-tube or other dressing that is
				  dry and intact.
EXAMPLE - Exclusion: This criterion does not include a
				  patient who has an order for wound care precautions alone without an order for
				  isolation precautions.
EXAMPLE - Exclusion: This criterion does not include a
				  patient who is incontinent and who requires the use of adult diapers.
2)
Oxygen
				Administration.
A patient with an order requiring the administration of
				supplemental oxygen by a third party assistant/attendant or requiring the
				regulation or adjustment of oxygen prior to and continuing through transport,
				and who is expected to require supplemental oxygen at the destination.
EXAMPLE - Inclusion: This criterion includes a patient for
				  whom there is a reasonable medical expectation that the flow rate will need to
				  be adjusted, and who requires pulse oxygen oximetry to guide administered flow
				  rate with a prior order indicating the threshold level at or above which the
				  oxygen saturation should be maintained.
EXAMPLE - Inclusion: This criterion includes a patient who
				  has an order that specifies oxygen is to be administered by mask, nasal cannula
				  or collar over tracheostomy at a specific flow rate (liters per minute).
EXAMPLE - Inclusion: This criterion includes a patient who
				  has supplemental oxygen that is required and is administered prior to transport
				  and for the duration of transport. Included in this group are patients who
				  require third party assistance to administer, regulate or adjust oxygen during
				  transport.
EXAMPLE - Exclusion: This criterion does not include patients
				  who are capable of self-administration of portable or home oxygen or who have
				  an available trained caregiver to administer oxygen.
3)
Ventilation/Advanced Airway
				Management
. A patient with an order for advanced continuous airway
				management prior to, during and after transport by means of an artificial
				airway through tracheal intubation (nasotracheal tube, orotracheal tube or
				tracheostomy tube).
EXAMPLE - Inclusion: A patient who is quadriplegic that
				  requires advanced airway management including mechanical ventilation during
				  transport.
EXAMPLE - Inclusion: A patient that requires continuous
				  airway support via nasotracheal intubation, endotracheal intubation or
				  tracheostomy, including the need for suctioning or the potential need for
				  suctioning during transport.
4)
Suctioning.
A patient with an
				order requiring suctioning to maintain his or her airway, or who requires
				assisted ventilation and/or apnea monitoring.
EXAMPLE - Inclusion: This criterion includes any patient
				  requiring deep suctioning to maintain the patient's airway.
EXAMPLE - Inclusion: This criterion includes a patient who
				  requires en route suctioning by another person as documented through an order
				  and prior medical condition.
EXAMPLE - Inclusion: This includes a patient who is in need
				  of a secure airway before transport is initiated. Orders should provide
				  specific directives such as assisted ventilation settings, oxygen concentration
				  or flow rate and need for pulse oximetry.
EXAMPLE - Exclusion: This criterion does not include a
				  patient who requires en route suctioning that can be administered by a trained
				  caregiver available to travel with the patient.
EXAMPLE - Exclusion: This criterion does not include a
				  patient who has a longstanding established tracheostomy with spontaneous
				  respiratory effort without need for any type of assisted ventilation or that
				  does not require medical monitoring or suctioning.
5)
Intravenous Fluid
				Administration.
A patient who has an order for the administration or
				monitoring of the ongoing administration of intravenous fluids prior to, during
				and after transport.
EXAMPLE - Inclusion: This criterion includes a patient who
				  has orders that specify the type of intravenous fluids, rate of administration
				  and site through which the fluids are to be administered.
EXAMPLE - Inclusion: This criterion includes intravenous
				  fluid administration that is required during transport.
EXAMPLE - Exclusion: This criterion does not include a
				  patient with a saline lock, a heparin lock, a peripherally inserted central
				  catheter (PICC) or an infusion port for which ongoing administration of
				  intravenous fluids or chemotherapy is not required during the transport to the
				  destination.
6)
Chemical Restraints.
A patient to whom a chemical restraint is
				administered during transport or a patient who is under the influence of a
				previously-administered chemical restraint prior to transport. Requires an
				order for a chemical restraint that is administered for the explicit purpose of
				reducing a patient's functional capacity because the patient presents a danger
				to physical safety of himself or herself and/or others during transport. The
				medication type must be documented.
EXAMPLE - Inclusion: This criterion includes a patient when
				  the chemical restraint administered requires close surveillance of a patient's
				  cardio-respiratory status, due to the central nervous system or respiratory
				  system depressant resulting from the chemical restraint administered, prior to
				  or during transport.
EXAMPLE - Exclusion: This criterion does not include a
				  patient receiving the administration of psychotropic medications routinely
				  taken for a pre-existing mental illness, unless there is an acute exacerbation
				  of a psychiatric condition.
EXAMPLE - Exclusion: This criterion does not include a
				  patient receiving the administration of routinely taken sedative
				  medications.
7)
Physical Restraint.
A patient who has an order for physical
				restraints that are required prior to transport and that are maintained for the
				duration of transport.
EXAMPLE - Inclusion: This criterion includes a patient with
				  an order for physical restraint administered for the explicit purpose of
				  reducing a patient's functional capacity because the patient presents a danger
				  to the physical safety of himself or herself and/or others during transport.
				  This criterion requires an order for the type of physical restraint and
				  monitoring required during the transport.
EXAMPLE - Inclusion: This criterion includes a patient being
				  transported from or to a restrained facility, holding center or lockdown
				  facility.
EXAMPLE - Exclusion: This criterion does not include a
				  patient with an order for simple safety straps.
8)
One-On-One Supervision
. A
				patient who has an order requiring one-on-one supervision due to a condition
				that places the patient and/or others at a risk of harm or elopement for the
				duration of the transport.
EXAMPLE - Inclusion: This criterion includes a patient who
				  has a psychiatric condition or disease who is receiving medical care for an
				  acute psychiatric crisis.
EXAMPLE - Exclusion: This criterion does not include a
				  patient who has a history of a psychiatric condition but is not in an acute
				  psychiatric crisis or condition.
EXAMPLE - Exclusion: This criterion does not include a
				  patient who has a diagnosis of dementia, including Alzheimer's disease, other
				  altered mental status or neurological condition, who is easily directed.
9)
Specialized
				Monitoring.
A patient who has an order requiring cardiac and/or
				respiratory monitoring, or hemodynamic monitoring, prior to, during and after
				transport.
EXAMPLE - Inclusion: This criterion includes a patient who
				  has been monitored via telemetry at the transferring facility for an
				  arrhythmia, who continues to need telemetry monitoring during the transport,
				  and who is expected to require telemetry monitoring after transport.
EXAMPLE - Inclusion: This criterion includes a patient who
				  has an order for hemodynamic monitoring during transport.
EXAMPLE - Inclusion: This criterion includes a patient who
				  has received a central nervous system and/or respiratory system depressant
				  medication who requires cardiac and/or respiratory or hemodynamic monitoring.
				  This criterion requires the documentation of the name, dosage, route, date and
				  time of the medication administered. It also requires an order for the specific
				  type of monitoring required.
EXAMPLE - Exclusion: This criterion does not include a
				  patient who was not receiving cardiac monitoring or hemodynamic monitoring at
				  the transferring facility and who is not expected to require cardiac monitoring
				  or hemodynamic monitoring at the destination.
10)
Special
				Handling/Positioning
. A patient who has an order for specialized
				handling for the purpose of positioning during transport. This criterion
				requires an order that documents the condition and the type of specialized
				handling and/or positioning that is required to transport to the destination.
EXAMPLE - Inclusion: This includes a patient who requires
				  specialized handling and positioning during transport, as well as the
				  assistance of medically trained personnel to avoid further injury during
				  transport. This criterion requires an order that documents the significant
				  mobility deficit and the type of special positioning required.
EXAMPLE - Inclusion: The patient's diagnosis and the order
				  for non-emergent ambulance transportation supports the need for special
				  positioning due to contractures, spica cast, recent extremity fractures (e.g.,
				  post-operative hip) or other conditions, and the specific type of positioning
				  required prior, during and after transport is appropriately documented in a
				  order.
EXAMPLE - Inclusion: The criterion includes a patient
				  utilizing an orthopedic device due to a medical condition requiring the use of
				  a backboard or in halo traction. This criterion also includes patients who have
				  external fixation, including external traction devices, which make it
				  impractical for the patient to be positioned in a wheelchair or standard car
				  seat. This criterion requires an order for non-emergent ambulance
				  transportation and specialized handling for an orthopedic device or condition.
				  The order must include the specific type of positioning required at the time of
				  transport and through transport to the destination.
EXAMPLE - Inclusion: The criterion includes a patient with a
				  medical diagnosis of multiple myeloma who has a history of pathologic fractures
				  compromising his or her spinal cord causing paraplegia.
EXAMPLE - Exclusion: This criterion does not include a
				  patient who is bed confined* but for whom there is no order or need for medical
				  care, aid, monitoring or treatment during transport as detailed in any of the
				  above criteria.
* Terms such as bedridden, bed confined, stretcher
				  patient or required restraints do not, by themselves, support medical
				  necessity. The determining factor is the condition of the patient. In addition,
				  "bed confined" is not meant to be the sole criterion to be used in determining
				  medical necessity.
EXAMPLE - Exclusion: This criterion does not include a
				  quadriplegic or paraplegic patient who can be transported by wheelchair or
				  stretcher, who does not meet any of the other criteria in this listing, or who
				  does not have an order for special positioning or medical monitoring.
EXAMPLE - Exclusion: This criterion does not include a
				  patient who has a Foley catheter, a G-tube, or other medical equipment for
				  which there is no medical need or order for monitoring during transport.
EXAMPLE - Exclusion: This criterion does not include the
				  transport of a patient with a stage I or II decubitus ulcer on the buttock with
				  a travel time less than one hour.
11)
Clinical Observation.
A
				patient who requires clinical observation is moving from one environment with
				24-hour clinical observation or treatment provided by certified or licensed
				nursing personnel to another environment with 24-hour clinical observation or
				treatment provided by certified or licensed nursing personnel. This criterion
				is based upon a patient's need for clinical observation or treatment prior to,
				during and after transport to the destination. This criterion is not satisfied
				based solely on the type of hospital or other facility from or to which the
				patient is being transferred.
EXAMPLE - Exclusion: This criterion excludes a patient
				  transferring from a hospital to a long term care facility that does not require
				  clinical observation or treatment as set forth in this subsection
				  (b)(11).