Wisconsin Administrative Code › Department of Health Services › DHS 101-109 - Medical Assistance › Chapter DHS 107 - Covered Services › Section DHS 107.23 - Transportation

Current through June 24, 2024
(1) COVERED SERVICES.
(a)
Purpose.
Transportation
				by ambulance, specialized medical vehicle (SMV) or county-approved or
				tribe-approved common carrier as defined under par. (d) 1., is a covered
				service when provided to a recipient in accordance with this section.
(b)
Transport by ambulance.
Ambulance transportation shall be a covered service if the recipient is
				suffering from an illness or injury which contraindicates transportation by
				other means, but only when provided:
1. For
				emergency care, when immediate medical treatment or examination is needed to
				deal with or guard against a worsening of the recipient's condition:
a. From the recipient's residence or the site
				of an illness or accident to a hospital, physician's office, or emergency care
				center;
b. From a nursing home to a
				hospital;
c. From a hospital to
				another hospital; and
2.
				For non-emergency care when authorized by a physician, physician assistant,
				nurse midwife or nurse practitioner by written documentation which states the
				specific medical problem requiring the non-emergency ambulance transport:
a. From a hospital or nursing home to the
				recipient's residence;
b. From a
				hospital to a nursing home;
c. From
				a nursing home to another nursing home, a hospital, a hospice care facility, or
				a dialysis center; or
d. From a
				recipient's residence or nursing home to a hospital or a physician's or
				dentist's office, if the transportation is to obtain a physician's or dentist's
				services which require special equipment for diagnosis or treatment that cannot
				be obtained in the nursing home or recipient's residence.
(c)
Transport by
				specialized medical vehicle (SMV).
1.
				In this paragraph, "indefinitely disabled" means a chronic, debilitating
				physical impairment which includes an inability to ambulate without personal
				assistance or requires the use of a mechanical aid such as a wheelchair, a
				walker or crutches, or a mental impairment which includes an inability to
				reliably and safely use common carrier transportation because of organic
				conditions affecting cognitive abilities or psychiatric symptoms that interfere
				with the recipient's safety or that might result in unsafe or unpredictable
				behavior. These symptoms and behaviors may include the inability to remain
				oriented to correct embarkation and debarkation points and times and the
				inability to remain safely seated in a common carrier cab or coach.
2. SMV transportation shall be a covered
				service if the recipient is legally blind or is indefinitely disabled as
				documented in writing by a physician, physician assistant, nurse midwife or
				nurse practitioner. The necessity for SMV transportation shall be documented by
				a physician, physician assistant, nurse midwife or nurse practitioner. The
				documentation shall indicate in a format determined by the department why the
				recipient's condition contraindicates transportation by a common carrier as
				defined under par. (d) 1., including accessible mass transit services, or by a
				private vehicle and shall be signed and dated by a physician, physician
				assistant, nurse midwife or nurse practitioner. For a legally blind or
				indefinitely disabled recipient, the documentation shall be rewritten annually.
				The documentation shall be placed in the file of the recipient maintained by
				the provider within 14 working days after the date of the physician's,
				physician assistant's, nurse midwife's or nurse practitioner's signing of the
				documentation and before any claim for reimbursement for the transportation is
				submitted.
3. If the recipient has
				not been declared legally blind or has not been determined by a physician,
				physician assistant, nurse midwife or nurse practitioner to be indefinitely
				disabled, the transportation provider shall obtain and maintain a physician's,
				physician assistant's, nurse midwife's or nurse practitioner's written
				documentation for SMV transportation. The documentation shall indicate in a
				format determined by the department why the recipient's condition
				contraindicates transportation by a common carrier, including accessible mass
				transit services, or by a private vehicle and shall state the specific medical
				problem preventing the use of a common carrier, as defined under par. (d) 1.,
				and the specific period of time the service may be provided. The documentation
				shall be signed and dated by a physician, physician assistant's, nurse midwife
				or nurse practitioner. The documentation shall be valid for a maximum of 90
				days from the date of the physician's, physician assistant's, nurse midwife's
				or nurse practitioner's signature. The documentation shall be placed in the
				file of the recipient maintained by the provider within 14 working days after
				the date of the physician's, physician assistant, nurse midwife's or nurse
				practitioner's signing of the documentation and before any claim for
				reimbursement for the transportation is submitted.
4. SMV transportation, including the return
				trip, is covered only if the transportation is to a location at which the
				recipient receives an MA-covered service on that day. SMV trips by cot or
				stretcher are covered if they have been prescribed by a physician, physician
				assistant, nurse midwife or nurse practitioner. In this subdivision, "cot or
				stretcher" means a bed-like device used to carry a patient in a horizontal or
				reclining position.
5. Charges for
				SMV unloaded mileage are reimbursable only when the SMV travels more than 20
				miles by the shortest route available to pick up a recipient and there is no
				other passenger in the vehicle, regardless of whether or not that passenger is
				an MA recipient. In this subdivision, "unloaded mileage" means the mileage
				travelled by the vehicle to pick up the recipient for transport to or from
				MA-covered services.
6. When a
				recipient does not meet the criteria under subd. 2., SMV transportation may be
				provided under par. (d) to an ambulatory recipient who needs transportation
				services to or from MA-covered services if no other transportation is
				available. The transportation provider shall obtain and maintain documentation
				as to the unavailability of other transportation. Records and charges for the
				transportation of ambulatory recipients shall be kept separate from records and
				charges for non-ambulatory recipients. Reimbursement shall be made under the
				common carrier provisions of par. (d).
(d)
Transport by county-approved or
				tribe-approved common carrier.
1. In
				this paragraph, "common carrier" means any mode of transportation approved by a
				county or tribal agency or designated agency, except an ambulance or an SMV
				unless the SMV is functioning under subd. 5.
2. Transportation of an MA recipient by a
				common carrier to a Wisconsin provider to receive MA-covered services shall be
				a covered service if the transportation is authorized by the county or tribal
				agency or its designated agency. Reimbursement shall be for the charges of the
				common carrier, for mileage expenses or a contracted amount the county or
				tribal agency or its designated agency has agreed to pay a common carrier. A
				county or tribal agency may develop its own transportation system or may enter
				into contracts with common carriers, individuals, private businesses, SMV
				providers and other governmental agencies to provide common carrier services. A
				county or tribe is limited in making this type of arrangement by sub. (3)
				(c).
3. Transportation of an MA
				recipient by a common carrier to an out-of-state provider, excluding a
				border-status provider, to receive MA-covered services shall be covered if the
				transportation is authorized by the county or tribal agency or its designated
				agency. The county or tribal agency or its designated agency may approve a
				request only if prior authorization has been received for the nonemergency
				medical services as required under s.
				DHS
				107.04. Reimbursement shall be for the charges of the
				common carrier, for mileage expenses or a contracted amount the county or
				tribal agency or its designated agency has agreed to pay the common
				carrier.
4. Related travel expenses
				may be covered when the necessary transportation is other than routine, such as
				transportation to receive a service that is available only in another county,
				state or country, and the transportation is prior authorized by the county or
				tribal agency or its designated agency. These expenses may include the cost of
				meals and commercial lodging enroute to MA-covered care, while receiving the
				care and when returning from the care, and the cost of an attendant to
				accompany the recipient. The necessity for an attendant, except for children
				under 16 years of age, shall be determined by a physician, physician assistant,
				nurse midwife or nurse practitioner with that determination documented and
				submitted to the county or tribal agency. Reimbursement for the cost of an
				attendant may include the attendant's transportation, lodging, meals and
				salary. If the attendant is a relative of the recipient, reimbursed costs are
				limited to transportation, commercial lodging and meals. Reimbursement for the
				costs of meals and commercial lodging shall be no greater than the amounts paid
				by the state to its employees for those expenses. The costs of more than one
				attendant shall be reimbursed only if the recipient's condition requires the
				physical presence of another person. Documentation stating the need for the
				second attendant shall be from a physician, physician assistant, nurse midwife
				or nurse practitioner and shall explain the need for the attendant and be
				maintained by the transportation provider if the provider is not a common
				carrier. If the provider is a common carrier, the statement of need shall be
				maintained by the county or tribal agency or its designated agency authorizing
				the transportation. If the length of attendant care is over 4 weeks in
				duration, the department shall determine the necessary expenses for the
				attendant or attendants after the first 4 weeks and at 4-week intervals
				thereafter. In this subdivision, "attendant" means a person needed by the
				transportation provider to assist with tasks necessary in transporting the
				recipient and that cannot be done by the driver or a person traveling with the
				recipient in order to receive training in the care of the recipient, and
				"relative" means a parent, grandparent, grandchild, stepparent, spouse, son,
				daughter, stepson, stepdaughter, brother, sister, half-brother or half-sister,
				with this relationship either by consanguinity or direct affinity.
5. If a recipient for emergency reasons
				beyond that person's control is unable to obtain the county or tribal agency's
				or designee's authorization for necessary transportation prior to the
				transportation, such as for a trip to a hospital emergency room on a weekend,
				the county or tribal agency or its designee may provide retroactive
				authorization. The county or tribal agency or its designee may require
				documentation from the medical service provider or the transportation provider,
				or both, to establish that the transportation was necessary.