(a) Scope

These regulations set forth the requirements for payment of Medical Transportation Services rendered to persons determined eligible for such services under provisions of Connecticut's Medical Assistance Program in accordance with Section 17-134d of the General Statutes of Connecticut.

(b) Definitions

1. (1) Additional Recipient

   An additional recipient is an eligible Medicaid recipient beyond the first recipient transported by a Medicaid transportation provider during the same trip.

2. (2) Additional Stop

   All trips have one pickup point and one drop-off point. An additional stop is a pickup point or drop-off point other than the initial pickup and final drop-off points. Additional stops occur when multiple recipients are transported during a single trip.

3. (3) Air Transportation

   Air transportation is transportation provided by a commercial airline.

4. (4) Alternative Method of Transportation

   If the most appropriate type of transportation for a recipient is not available, a different type of transportation may be utilized. This would be an alternative method of transportation.

5. (5) Ambulance

   An ambulance is a vehicle for transporting the sick and injured which is equipped and staffed to provide medical care during transit, and which is operating as an ambulance under the authority and in compliance with promulgated regulations of the Department of Health Services, Office of Emergency Medical Services, and registered as such by the Department of Motor Vehicles.

6. (6) Ambulance Night Call Charge

   An ambulance night call charge is an additional fee that may be paid when an ambulance service is dispatched between the hours of 7:00 P.M. and 7:00 A.M. inclusive.

7. (7) Appropriate Method of Transportation

   An appropriate method of transportation is the least expensive type of transportation which best meets the physical and medical circumstances of a recipient requiring transportation to a medical service.

8. (8) Assistance

   Assistance is when a recipient 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 recipient to reach the livery vehicle or the medical provider's site.

   This assistance is provided by an employee of the livery provider, the driver or a person in addition to the driver. This service is beyond a door-to-door service.

9. (9) Attendant

   An attendant is an employee of an invalid coach or wheelchair accessible livery provider, and is a person in the vehicle in addition to the driver, who provides assistance in the transportation of passengers.

10. (10) Attendant Services

    Attendant services are when an attendant must physically assist a recipient from within or into a building and from within or into the medical provider's site. Without such assistance it would be unsafe or impossible for the recipient to reach the invalid coach or wheelchair accessible livery vehicle or the medical provider's site. This service is beyond a door-to-door service.

11. (11) Available Transportation

    Available transportation means that a public transportation system, an enrolled Medicaid provider, organization, agency, or individual offers appropriate transportation services to a recipient who requires transportation.

12. (12) Border Provider

    A border provider is a provider located in a state bordering Connecticut, in an area that allows it to generally serve Connecticut residents, and who is enrolled as and treated as a Connecticut Medicaid provider. Such providers are certified and/or licensed by the applicable agency in their state.

13. (13) Cancelled Call

    A cancelled call is notification to the transportation provider not to provide services to a recipient, prior to the time the vehicle is enroute to the pickup point.

14. (14) Critical Care Helicopter

    A critical care helicopter is an aircraft which is operating as a critical care helicopter and in compliance with promulgated regulations under the authority of the Department of Health Services, Office of Emergency Medical Services. A critical care helicopter has mobile intensive care capabilities and is called to the scenes of severe accidents or illness.

15. (15) Department

    The Department means the Department of Income Maintenance.

16. (16) Emergency

    An emergency is defined as a medical condition (including labor and delivery) manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placing the patient's health in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part.

17. (17) Emergency Ambulance Trip

    1. (A) a hospital emergency room; or
    2. (B) a general hospital or a psychiatric facility where a nonscheduled admission results; or
    3. (C) a general hospital or a psychiatric facility where an emergency admission results after a recipient was seen at a hospital emergency room; or
    4. (D) a second facility because an emergency medical service was not available at the original emergency room; or
    5. (E) a critical care helicopter.

    An emergency ambulance trip is an ambulance trip made in accordance with the Department's definition of emergency and has as its destination:

18. (18) Helicopter Assist

    A helicopter assist is medical care provided at the scene to a recipient when such recipient is ultimately transported by a critical care helicopter.

19. (19) Invalid Coach

    An invalid coach is a vehicle used exclusively for the transportation of non-ambulatory patients and is operating as an invalid coach under the authority and in compliance with promulgated regulations of the Department of Health Services, Office of Emergency Medical Services, and registered as such by the Department of Motor Vehicles, or is a wheelchair accessible livery vehicle.

20. (20) Livery

    A livery vehicle is a sedan or van type vehicle capable of carrying up to ten passengers used for the transportation of ambulatory patients, who may require assistance, and which is operated by a livery carrier under the authority and in compliance with the statutes and regulations of the Department of Transportation and/or a transit district and registered as a livery vehicle by the Department of Motor Vehicles. Livery service is a door-to-door service.

    A livery vehicle does not include a vehicle registered as a service bus vehicle with the following exception. If the Commissioner determines, in his/her sole discretion, that for access or other reasons use of service bus vehicles is appropriate, equitable and in the best interests of the state, he/she may authorize use of service bus registered vehicles and may impose any additional insurance or other requirements or limitations which he/she deems appropriate. Said authorization must be in writing.

21. (21) Loaded Mileage

    Loaded mileage is the distance traveled by a motor vehicle while carrying passengers from a pickup point to a drop-off point. Mileage between Connecticut towns is determined in accordance with the Public Utility Control Docket Document (PUCA) #6770-A.

22. (22) Noncontiguous Town

    Noncontiguous town is a town which does not border the town in which a provider's headquarters is housed. Noncontiguous towns are towns which do not border each other.

23. (23) Non-Emergency Ambulance Trip

    Non-emergency ambulance trip is a pre-arranged ambulance trip that is not responding to an emergency injury or illness. However, ambulance services are needed because a recipient may require medical care during transit, which an ambulance is equipped and staffed to provide.

24. (24) No-show

    No-show is when a recipient fails to utilize a transportation service approved in writing by the Department, and which is not cancelled.

25. (25) Not Ambulatory

    An individual who is not ambulatory is unable to walk despite the possible use of assistive devices (e.g., cane, crutch, walker) and/or the assistance of an attendant.

26. (26) Nursing Home

    A nursing home is an intermediate care or skilled nursing facility (ICF, SNF, or ICF/MR) or Chronic Disease Hospital.

27. (27) Other Commercial Carrier

    Other commercial carriers are those regulated carriers other than taxi, livery, wheelchair accessible livery, ambulance, invalid coach, and air transportation that transport the public for a fee and which meet all applicable state and federal permit and licensure requirements to operate as such.

28. (28) Out-of-State Trip

    An out-of-state trip is a trip originating or ending outside Connecticut that is to transport a patient to or from a medical provider that is not located in Connecticut and is not a border provider.

29. (29) Prior Authorization

    Prior authorization means approval for a service from the Department or the Department's agent before the provider actually provides the service. In order to receive reimbursement from the Department a provider must comply with all prior authorization requirements. The Department in its sole discretion determines what information is necessary in order to approve a prior authorization request.

30. (30) Private Transportation

    Private transportation is transportation by a vehicle owned by a recipient or by a friend, relative, acquaintance or other individual, provided the vehicle is not licensed for commercial carriage. Individual does not mean communities, companies, corporations, societies or associations.

31. (31) Provider Agreement

    The provider agreement is the signed written contractual agreement between the Department and the provider of services or goods.

32. (32) Provider Headquarters

    Provider headquarters is the provider's base of operations closest to the pickup point. A provider may have more than one (1) headquarters.

33. (33) PUCA Document

    PUCA Document is the Department of Public Utility Control Docket Document #6770-A and all its supplements which specify the mileage between Connecticut towns.

34. (34) Recipient

    Recipient means a person eligible for services under the Department's Medical Assistance Program.

35. (35) Round Trip

    A round trip is the dispatching of a vehicle to the recipient(s) pickup point, transporting the recipient(s) to a medical provider and transporting the recipient(s) back to the pick-up point.

36. (36) Shared Ride

    A shared ride is when more than one recipient occupies a vehicle during the same trip.

37. (37) Special Attendant

    A special attendant is a second attendant who is an employee of the ambulance provider, and who is in the vehicle in addition to the driver and one attendant. This attendant is needed due to the recipient's medical condition.

38. (38) Taxi

    A taxi is a vehicle operating as a taxi under the authority and in compliance with promulgated regulations of the Department of Transportation and/or a transit district and registered as such by the Department of Motor Vehicles.

39. (39) Trip–Ambulance, Invalid Coach, Taxi and Wheelchair Accessible Livery

    A trip is the dispatching of an empty vehicle to the recipient pickup point and transporting the recipient to a medical provider, or from a medical provider to the drop-off point.

40. (40) Trip–Livery

    A livery trip is the dispatching of an empty livery vehicle to the recipient(s) pickup point and transporting the recipient(s) to a medical provider or from a medical provider to the drop-off point. A trip for livery services begins when an empty vehicle picks up a recipient(s) and ends when the last recipient is dropped off and the vehicle is empty.

41. (41) Unloaded Mileage

    Unloaded mileage is the distance traveled by the motor vehicle carrying no passengers, enroute to the point of pickup or, enroute from the point of drop-off.

42. (42) Unpaid Health Care

    Unpaid health care is a service(s) provided to a recipient which is voluntary in nature, and usually provided by a family member, neighbor, friend or other person(s) within the individual's support system.

43. (43) Waiting Time

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

44. (44) Wheelchair Accessible Livery

    A wheelchair accessible livery vehicle is a vehicle specifically designed for the transportation of wheelchair mobile patients, and which is operating as a wheelchair accessible livery, under the authority and in compliance with promulgated regulations of the Department of Transportation and/or a transit district and registered as such by the Department of Motor Vehicles. Wheelchair accessible livery vehicles are treated the same as invalid coach vehicles.

For purposes of Section 17-134d-33, the following definitions apply:

(c) Provider Participation

In order to participate in the Medicaid program and receive payment directly from the Department, all commercial transportation providers must: 1. be regulated carriers, 2. meet and maintain all applicable state and federal permit and licensure requirements, and vehicle registration requirements, 3. provide the Department with a copy of their approved permit or license, 4. also meet and maintain all applicable Departmental enrollment requirements and 5. have a signed provider agreement on file. It is signed by the provider upon application for enrollment into the Medicaid Program and is effective on the approved date of enrollment. The provider agreement specifies conditions and terms (regulations, standards and statutes) which govern the program and to which the provider is mandated to adhere in order to participate in the program. There are no enrollment requirements for private transportation.

(d) Eligibility

Payment for medical transportation services is available for all Medicaid eligible recipients subject to the conditions and limitations which apply to these services.

(e) Services Covered and Limitations

1. (1) Services Covered

   1. (A) Medicaid assures that necessary transportation is available for recipients to and from providers of medical services covered by Medicaid, and, subject to this regulation, may pay for such transportation.
   2. (B) Payment for transportation may be made for eligible recipients under the Medicaid program, except as otherwise provided in these regulations, when needed to obtain necessary medical services covered by Medicaid, and when it is not available from volunteer organizations, other agencies, personal resources, or is not included in the medical provider's Medicaid rate.
   3. (C) Transportation may be paid only for trips to or from a medical provider for the purpose of obtaining medical services covered by Medicaid. If the medical service is paid for by a source other than the Department, the Department may pay for the transportation as long as the medical service is necessary and is covered by Medicaid.

2. (2) Service Limitations

   1. (A) The Department reserves the right to make the determination as to which type of transportation is the most appropriate for a recipient.
   2. (B) The Department reserves the right to limit its payment of transportation to the nearest appropriate provider of medical services when it has made a determination that traveling further distances provides no medical benefit to the recipient.
   3. (C) The Department may pay for only the least expensive appropriate method of transportation, depending on the availability of the service and the physical and medical, circumstances of the patient.
   4. (D) Trips for out-of-state medical services may be paid for when the medical service meets the conditions for payment. Out-of-state services shall be paid for to the same extent as in-state services. The conditions are:

(i) The out-of-state medical services are needed because of a medical emergency; or

1. (ii) Medical services are needed because the recipient's health would be endangered if required to travel to Connecticut; or
2. (iii) The Department determines, on the basis of medical advice, that the needed medical services, or necessary supplementary resources, are more readily available in another state; or
3. (iv) It is general practice for recipients in particular localities of Connecticut to use the medical resources in another bordering state. The Department will allow for providers in these localities to be treated in the same manner as Connecticut providers. These providers are called border providers. Note: trips to receive a medical service from a border provider are not considered out-of-state trips.
4. (E) Ambulance Transportation

(bb) the patient's diagnosis indicates that the patient's condition might deteriorate in transit to the point where medical attention would be needed; or,

1. (cc) the patient's condition requires hand and/or feet restraints; or
2. (dd) the ambulance is responding to an emergency; or,

(ee) no alternative less expensive means of transportation is available as determined by the Department.

1. (ii) Loaded mileage may be paid for ambulance services if the vehicle must cross a town line in order to transport a recipient to or from a medical provider. One mileage charge for the mileage covered may be paid, regardless of the number of recipients transported. Mileage between towns is determined and paid according to the PUCA Document.
2. (iii) The Department shall not pay for a recipient who fails to utilize ambulance services.
3. (F) Invalid Coach

(bb) no alternative less expensive means of transportation is available as determined by the Department.

1. (ii) Loaded mileage may be paid for invalid coach if the vehicle must cross a town line in order to transport a recipient to or from a medical provider. One mileage charge for the mileage covered shall be paid, regardless of the number of recipients transported. Mileage between towns is determined and paid according to the PUCA Document.
2. (iii) Wheelchair accessible livery services are treated the same as invalid coach services.
3. (iv) The Department shall not pay for a recipient who fails to utilize invalid coach services.
4. (G) Livery

(bb) no alternative less expensive means of transportation is available as determined by the Department.

1. (ii) Livery providers are responsible for alerting the client of the vehicle's arrival and assisting the client into the vehicle if necessary.
2. (iii) If a recipient fails to use approved livery services and the trip was not cancelled, the provider may be paid only for a base rate, additional stop or mileage applicable to that recipient as set forth in subsection (i) (9) (D) Payment Limitations.
3. (iv) Payment may be made for waiting time, after the first fifteen minutes waited. No payment will be made for the first fifteen minutes waited.

(v) Loaded mileage may be paid for livery if the vehicle must cross a town line in order to transport a recipient to or from a medical provider. Mileage between Connecticut towns is determined and paid according to the PUCA Document.

1. (vi) Payment, in accordance with these regulations, shall be made by the Department for services provided which were approved by a written prior authorization form.
2. (H) Wheelchair Accessible Livery

(bb) no alternative less expensive means of transportation is available as determined by the Department.

1. (ii) Wheelchair accessible livery providers are responsible for alerting the client of the vehicle's arrival and assisting the client into the vehicle if necessary.
2. (iii) Wheelchair accessible livery providers must meet all Departmental regulations for invalid coach.
3. (iv) The Department shall not pay for a recipient who fails to utilize wheelchair accessible livery services.
4. (I) Taxi

(i) Payment may be made for taxi transportation provided no alternative less expensive means of transportation is available as determined by the Department.

1. (ii) The Department shall not pay for a recipient who fails to utilize taxi services.

2. (J) Air Transportation

   Payment may be made for transporting a patient by airplane provided:

(i) a medical condition dictates the use of air transportation; or,

1. (ii) it is less expensive than an alternative means of transportation; or,
2. (iii) time constraints dictate the use of such transportation.

3. (K) Critical Care Helicopter

   Payment may be made for critical care helicopter service if the utilization of this helicopter is justified rather than ground ambulance service. The factors that will be considered in determining if the use of a critical care helicopter was appropriate are those criteria published by the Department of Health Services, Office of Emergency Medical Services as Minimum Quality Standards for critical care helicopter responses, (Section 6.2), as they may be amended from time to time.

   For informational purposes, as of the date of the adoption of this regulation, the factors are:

(i) condition of the patient;

1. (ii) time needed for rescue/extrication;
2. (iii) transport time to closest facility;
3. (iv) landing conditions;

(v) traffic conditions present at the time;

1. (vi) remoteness of the location; and
2. (vii) multiple number of patients.

3. (L) Other Commercial Carriers

   Payment may be made for transportation by means of other commercial carriers provided no other alternative less expensive means of transportation is available as determined by the Department.

4. (M) Private Transportation

   Payment may be made for the transporting of a patient by private transportation when no alternative less expensive transportation is available as determined by the Department.

5. (N) Exclusive Service Contracts

   Providers who have contracts with organizations to provide transportation services shall not be paid higher rates for services than what the Department would pay another available provider for these same services. The Department is not bound to use the services of a provider because this provider has an exclusive contract with an organization.

6. (O) When an alternative method of transportation must be used for a recipient, the Department must approve the use of this type of transportation if it exceeds the appropriate type of transportation needed by the recipient.
7. (P) Services covered are limited to those listed in the Department's fee schedule.
8. (Q) When the Department approves a certain type of transportation and a provider uses a higher level of transportation, the Department is not bound to pay for the higher level of transportation.

9. (3) Services Not Covered

   1. (A) For nursing home patients, transportation to a medical service shall not be paid:

(i) If the medical service is one that the nursing home is required to provide as part of the per diem payment to the home; or

1. (ii) If the service is one connected with the admission physical, annual physical or dental exams required by the public health code.
2. (B) Payment shall not be made to transport a relative or a foster parent of an eligible Medicaid recipient, unless the person needs to be present at and during the medical service being provided to the patient. For example, when family therapy is being provided to a child, the parent may be transported to the therapy service. Such payments shall be made in accordance with all other transportation regulations.
3. (C) Payment shall not be made for transportation services that are not approved, which require prior authorization by the Department.
4. (D) The Department shall not pay for transportation of a recipient to a medical provider when the visit is for the sole purpose of the recipient picking up a prescription or a written prescription order.
5. (E) The Department shall not pay for cancelled calls.
6. (F) The Department shall not pay for transportation to a medical provider when the visit is solely to pick up an item which does not require a fitting.
7. (G) The Department shall not pay for no shows for ambulance, invalid coach, wheelchair accessible livery or taxi services.
8. (H) Payment shall not be made to transport a recipient who is a hospital inpatient to any medical service outside the hospital except for a computerized axial tomography (CAT) scan and/or for magnetic resonance imaging (MRI). Transportation for these services is covered only when the services are not available in the hospital where the recipient is an inpatient.
9. (I) Payment shall not be made to transport a relative or a foster parent of a recipient who is a hospital inpatient, unless the person needs to be trained to provide unpaid health care in the home to the recipient. Without this health care being provided the recipient would not be able to return home.

(f) Need for Service and Authorization Process

1. (1) Need for Service

   The Department may pay for transportation services which are required in order for a recipient to receive necessary medical care which is covered under the Medicaid Program.

2. (2) Prior Authorization

   1. (A) Ambulance

   All transportation services require written prior authorization, except emergency ambulance, non-emergency ambulance with designated medical conditions, in-state invalid coach and wheelchair accessible livery services with designated diagnoses, bus, train, and private transportation within the same town.

   Prior authorization for transportation services is required as listed below. Prior authorization, when required, may be given for single or multiple trips, depending on the circumstances. Multiple trips, where medical need has been shown, can be authorized for periods up to a maximum of three months at a time. An example would be a recipient receiving dialysis services.

(i) Prior authorization is required for all non-emergency ambulance trips without designated medical conditions. A list of these conditions is contained in Appendix B to this policy.

1. (ii) Services taking place after Departmental working hours, that could not be arranged during working hours prior to the trip, require after-the-fact approval by the Department. These requests must be in writing. Written requests for such authorization must be received by the Department within fifteen (15) working days following the date the transportation services were provided. Otherwise the service shall not be covered. The same limitations and requirements for appropriateness of service apply for after hours services.

   Consideration will be given to after-the-fact authorization requests received after fifteen (15) working days, if the failure to submit an authorization was for a recipient who had a pending application with the Department, or had other third party coverage. A written authorization request for the above situations must be received within ninety (90) working days of the date the transportation services were provided. Verification of other third party payment or denial must be attached to the request.

2. (B) Invalid Coach and Wheelchair Accessible Livery

(i) Prior authorization is required for all out-of-state trips regardless of the recipient's diagnosis.

1. (ii) Prior authorization is required for all in state trips unless the recipient's diagnosis indicates the need for an invalid coach. A list of these diagnoses is contained in Appendix A to this policy. The relevant diagnosis is the one that relates to the need for invalid coach services, and not necessarily the diagnosis for which the recipient is receiving treatment.

2. (iii) Services taking place after Departmental working hours, that could not be arranged during working hours prior to the trip, require after-the-fact approval by the Department. These requests must be in writing. Written requests for such authorization must be received by the Department within fifteen (15) working days following the date the transportation services were provided. Otherwise the service will not be covered. The same limitations and requirements for appropriateness of service apply for after hours services.

   Consideration will be given to after-the-fact authorization requests received after fifteen (15) working days, if the failure to submit an authorization was for a recipient who had a pending application with the Department. A written authorization request for the above situations must be received within ninety (90) working days of the date the transportation services were provided.

3. (C) Livery and Taxi Services

(i) Prior authorization is required for all services by nursing homes for their nursing home recipients.

1. (ii) Services for recipients taking place after Departmental working hours, that could not be arranged during working hours prior to the trip, require after-the-fact approval by the Department. These requests must be in writing. Requests for such authorization must be received by the Department within fifteen (15) working days following the date the transportation services were provided. Otherwise the service will not be covered. The same limitations and requirements for appropriateness of transportation apply for after hours services.

   Consideration will be given to after-the-fact authorization requests received after fifteen (15) working days, if the failure to submit an authorization was for a recipient who had a pending application with the Department. A written authorization request for the above situations must be received within ninety (90) working days of the date the transportation services were provided.

2. (D) Other Commercial Carriers and Air Transportation

   All non-emergency commercial carrier transportation except bus and train transportation within the same town require prior authorization.

   However reimbursement will be made only if the recipient documents a visit to a medical provider for a needed service. Requests for reimbursement must be made within thirty (30) days of the date of the transportation.

3. (E) Private Transportation

   Prior authorization is required for trips between towns and out-of-state private transportation. No prior authorization is required for private transportation for trips within a town. Reimbursement for all private transportation will be made only if the recipient documents a visit to a medical provider for a needed service. Requests for private transportation reimbursement must be made within thirty (30) days of the date of the transportation need.

4. (3) Prior Authorization Process

   1. (A) Ambulance, Invalid Coach and Wheelchair Accessible Livery

      Prior authorization for ambulance, invalid coach and wheelchair accessible livery trips is obtained from the Department's Central Office. The authorization request must be made by the transportation provider. Verbal authorization may be obtained during Departmental business hours from the Central Office.

      To obtain authorization the following information is required:

(i) The provider name.

1. (ii) The recipient's name and Medicaid number.
2. (iii) Relevant diagnosis of the recipient which indicates the need for the type of transportation.
3. (iv) Origin and destination of trip.

(v) Reason for trip.

1. (vi) Date of trip.
2. (vii) Town code(s).
3. (viii) Procedure code(s).
4. (B) Livery, Taxi, Bus, Train, Air, Private and Other Commercial Carriers

(i) Out-of-State Trips

All out-of-state trips require prior authorization from the Department's Central Office, however, arrangements are made through the Department's District Office, as follows:

(bb) the District Office contacts Central Office;

1. (cc) the Department's Central Office staff will determine if the out-of-state service meets the criteria for payment, determine if the service has been approved, if prior authorization is required, and determine the most appropriate level of transportation;
2. (dd) Central Office will inform the District Office of the decision; and

(ee) the District Office will arrange for livery, taxi, bus, train or private transportation and Central Office will arrange for air transportation.

1. (ii) Livery, Taxi Trips from Nursing Home

   All livery, taxi trips from nursing homes require prior authorization from the Department's Central Office. The authorization request must be made by the transportation provider. Verbal authorization may be obtained during Departmental business hours from the Central Office.

   To obtain authorization the following information is required:

(bb) The recipient's name and Medicaid number.

1. (cc) Relevant diagnosis of the recipient which indicates the need for the type of transportation.
2. (dd) Origin and destination of trip.

(gg) Town code(s).

1. (iii) Other Livery, Taxi Trips

   Trips by livery and taxi other than those listed in (i) and (ii) above are arranged and authorized by the District Office, as follows:

(bb) the District Office is responsible for verifying that the trip is for a medical purpose, and that the particular type of transportation is appropriate, necessary, and the least costly means; and if so

1. (cc) the District Office will then arrange and authorize the trip.

2. (iv) Bus, Train and Private Transportation

   No prior authorization is required for trips within the same town, however, reimbursement will be made to the Medicaid recipient, only if the Department receives documentation of a visit to a medical provider. Documentation consists of a signed statement by the medical provider or his authorized representative, or a completed Departmental W-610 Form. Requests for transportation reimbursement must be made within thirty (30) days of the date of the transportation need.

   Trips between towns require prior authorization. These trips are approved and arranged by the District Office, as follows:

(bb) the District Office is responsible for verifying that the trip is for a medical purpose, and that the particular type of transportation is appropriate, necessary, and the least costly means; and if so

1. (cc) the District Office will arrange and authorize the trip; and then
2. (dd) the District Office arranges for reimbursement to be sent to the recipient.

(v) Other Commercial Carrier

1. (vi) Air Transportation

   Air transportation requires prior authorization from the Department's Central Office to be obtained as follows:

When non-emergency transportation involves other commercial carriers, prior authorization must be obtained from the District Office. The District Office will either arrange the transportation through a travel agent or the provider of service.

(bb) Central Office will determine:

1. (11) if the medical service for which transportation is needed requires prior authorization, that the authorization has been approved;
2. (22) if the service is out-of-state, that the service meets the criteria for out-of-state services; and
3. (33) if air transportation is the most appropriate level of transportation, and, if so, will contact the ticket agent to make the arrangements.

(g) Other

1. (1) When two or more providers offer the same service, the least expensive one is used; there is no obligation to divide the business between them.
2. (2) When two or more providers offer the same service, at the same rate, the Department may consider whether to divide the business between them in proportion to the quantity of business each provider can furnish and based on a provider's past performance and any other factors the Department may deem appropriate. Whether to divide the business and how to divide the business shall be determined by the Department in its sole discretion.
3. (3) The Department shall not pay for transportation to a medical service if the provider of that medical service furnishes free transportation or has an obligation to furnish transportation.
4. (4) Providers of medical transportation must maintain records to support claims made for payment, including, but not limited to, daily drivers logs and other documents which record at least for each trip: patient's name, license number of vehicle used, the vehicle's pickup and drop-off time and place, the name of an attendant, if one is used, and the vehicle's pickup and drop off odometer reading for all out-of-state trips. All documentation shall be made available upon request to authorized Department, state and federal personnel in accordance with state and federal law.
5. (5) In addition to the records all providers must maintain for the Department, livery and taxi providers must keep a log for services that could not be authorized in advance, which is signed by a recipient when a transportation service is received.
6. (6) If the most appropriate transportation is not available, and prior authorization was not received for the alternative method of transportation utilized, the transportation company providing the service must document in the records and on the billing form why the appropriate transportation was not available. The Department in its sole discretion shall determine which level of payment is appropriate.
7. (7) The Department reserves the right to consider recipient and Departmental needs, when selecting which provider will render the service.
8. (8) Livery providers are responsible for alerting the recipient of the vehicle's arrival and assisting the recipient into and out of the vehicle.
9. (9) Mileage for a vehicle crossing Connecticut town lines is calculated and paid by the Department to providers according to the PUCA Document.
10. (10) The Department, in its sole discretion, may disallow some or all of the reimbursement paid to the provider for services rendered by a vehicle which was out of compliance with any of the requirements of subsection (c) Provider Participation as set forth above. The Department, in its sole discretion, in addition to, or in lieu of the disallowance of reimbursement, may suspend or terminate the provider from the Medicaid Program for any such violation.

11. (11) Nursing Homes

    1. (A) Nursing home staff is responsible for assisting recipients to and from a livery vehicle at the nursing home site.
    2. (B) Nursing home staff is responsible for determining if the cost of providing the medical service in the nursing home is less costly than providing the medical service outside the home. This cost effective determination would include the consideration of the cost of the transportation and the medical service compared to the cost of providing the medical service in the nursing home. When possible and appropriate, the needed medical service should be provided in the nursing home. If it is necessary to transport a recipient to a medical service because a medical provider is not available to come to the home, written documentation must be entered in the recipient's case record.
12. (12) Payment for transportation may be made for an applicant with the Department, when the transportation is to a medical evaluation requested by the Department in order to determine eligibility.
13. (13) Failure to maintain any of the documentation required by this regulation may result in the Department disallowing some or all of the reimbursement paid to the provider for services rendered.

(h) Billing

1. (1) Ambulance, Invalid Coach and Travel Agents

   The provider submits the bill for service on the HCFA 1500, "Health Insurance Claim Form," to the Department's fiscal agent.

2. (2) Livery

   The provider of service submits the bill on the Departmental livery claim form to the Department's fiscal agent.

3. (3) Taxi

   The provider of service submits the bill on the Departmental taxi claim form to the Department's fiscal agent.

(i) Payment

1. (1) For all transportation payment shall be made at the lower of:

   1. (A) The usual and customary charge to the public, if applicable
   2. (B) The Medicare rate, if one exists
   3. (C) The fee, as published by the Department in its fee schedule or
   4. (D) The amount requested or billed

2. (2) Ambulance

   Ambulance providers may be paid for a trip, I.V. level life support services, advanced life support services, waiting time, loaded mileage, additional recipient transported, a night call charge, special attendant, paramedic intercept, helicopter assist, out-of-state tolls and for services provided to a recipient who is not subsequently transported by the ambulance provider in accordance with this regulation.

3. (3) Invalid Coach

   Invalid coach providers may be paid for a trip, waiting time, loaded mileage, additional recipient transported and attendant services in accordance with this regulation.

4. (4) Livery

   Livery providers may be paid for a trip, loaded mileage, additional stops, waiting time, assistance, "no shows", and out-of-state tolls in accordance with this regulation.

5. (5) Taxi

   Taxi providers may be paid for trips by an all inclusive metered rate and out-of-state tolls in accordance with this regulation.

6. (6) Wheelchair Accessible Livery

   Wheelchair accessible livery providers may be paid for a trip, waiting time, loaded mileage, an additional recipient transported, and out-of-state tolls attendant services in accordance with this regulation.

7. (7) Payment may be made to:

   1. (A) the provider of service if an ambulance, invalid coach, taxi, or livery provider;
   2. (B) either the provider of the service, or an enrolled ticket agent, if the provider of service is any other commercial carrier except bus, or train;
   3. (C) the Medicaid recipient, if the transportation is by private means, bus or train.

8. (8) Payment Fees

   1. (A) The Commissioner of the Department establishes the fees contained in the Department's fee schedule.
   2. (B) Payment fees for out-of-state trips performed by out-of-state providers shall be established by the Commissioner of the Department.
   3. (C) The maximum payment for transportation services shall be at the fees established by the Department.

   4. (D) Wheelchair Accessible Livery.

      The Department's fees for wheelchair accessible livery shall be the same as the Department's fees for invalid coach services.

   5. (E) Private Transportation

      Payment may be made at the per mile fee established by the Department, but only if the total payment exceeds $1.00.

   6. (F) Other Commercial Carrier and Air Transportation

      Payment may be made at the lowest charge to the general public for the same service.

9. (9) Payment Limitations

   1. (A) Multiple Passengers—Taxi

      Taxi services are paid by the metered rate, regardless of the number of recipients transported.

   2. (B) Multiple Passengers—Livery

(i) If during a trip, a livery vehicle picks up more than one recipient at the same point and transports those recipients to the same destination, the livery service may be paid as if the service were provided for one recipient.

1. (ii) In the event that a livery provider picks up several Medicaid recipients at several different pickup points and drops those recipients off at one common destination point, the livery provider may be paid one base rate, plus a shared ride fee for each additional pickup point. If the provider picks up several Medicaid recipients at one pickup point, and drops those passengers off at several different destination points, the livery provider may be paid one base rate, plus a shared ride fee for each additional drop-off point. If more than one recipient is picked up or dropped off at any additional stop, only one shared ride fee shall be paid for that stop.
2. (iii) In the event that a livery provider picks up several Medicaid recipients each at a different pickup point and drops those recipients off each at a different destination point (i.e. no common pickup or drop-off points) and all pickups and drop-offs occur within the same town, the livery provider may be paid one base rate for each recipient transported.
3. (iv) In the event that a livery provider picks up several Medicaid recipients each at a different pickup point and drops those recipients off each at a different destination point (i.e. no common pickup or drop-off points) and the trip involves loaded mileage between towns, the livery provider may be paid one base rate plus a shared ride fee for each additional drop-off point plus one loaded mileage charge for each unduplicated portion of the trip mileage. If multiple recipients are in the vehicle and travel together during a portion of the trip, only one mileage charge shall be paid for the common portion of the trip.

(v) Only one loaded mileage charge may be paid for the total miles traveled between towns, regardless of the number of recipients transported. If multiple recipients are transported in one trip, the total mileage for the trip cannot be charged for each recipient. Mileage between towns is calculated and paid according to the PUCA Document.

1. (C) Cancelled Calls

   The Department shall not pay for cancelled calls for any type of transportation.

2. (D) No Show

   The Department may pay for a livery service approved in writing by the Department and not cancelled, which a recipient does not utilize, provided the vehicle went to the pickup point. For livery the base rate may be paid for a "no show" for single recipient trips. For multiple recipient trips, a base rate or an additional stop, whichever is appropriate, and mileage if appropriate may be paid for the portion of the trip incurred for the "no show." A "no show" fee will not be paid for nursing home residents.

3. (E) Waiting Time

   Waiting time shall only be paid when it is cost effective or the Department has determined it is necessary in order for a recipient to receive a medical service.

(i) Ambulance

1. (ii) Invalid Coach

   No payment shall be made for the first one-half hour of waiting; thereafter waiting time may be paid in fifteen (15) minute increments for all or any portion of the fifteen minutes.

   When waiting time is provided as part of a round trip, the Department shall not pay for two base rates and waiting time. One base rate and waiting time may be paid.

2. (iii) Livery

   No payment shall be made for the first fifteen minutes of waiting; thereafter waiting time will be paid in 15 minute increments for all or any of the fifteen minutes.

   When waiting time is provided as part of a round trip, the Department shall not pay for two trips and waiting time. One trip and waiting time may be paid.

3. (iv) Taxi

   Waiting time may be paid in accordance with the tariff established by the Department of Transportation and/or a state approved transit district and is considered part of the metered rate.

4. (F) Mileage

One-hour's waiting time may be paid for all or any portion of the first hour. After one hour of actual waiting time, additional waiting time may be paid in fifteen (15) minute increments for all or any portion of the fifteen minutes.

When waiting time is provided as part of a round trip, the Department shall not pay for two base rates and waiting time. One base rate and waiting time may be paid.

(i) Ambulance

1. (ii) Invalid Coach

   The Department may pay for loaded mileage if the vehicle must cross a town line in order to transport a recipient(s) to or from a medical provider. Loaded mileage shall be paid and calculated by the Department in accordance with PUCA Docket #6670-A and all its supplements.

2. (iii) Livery

The Department may pay for loaded mileage if the vehicle must cross a town line in order to transport a recipient(s) to or from a medical provider. Loaded mileage shall be paid and calculated by the Department in accordance with PUCA Docket #6770-A and all its supplements.

(bb) Wheelchair accessible livery may be paid at the same fees as invalid coach.

1. (iv) Taxi

   Mileage may be paid in accordance with the tariff established by the Department of Transportation and/or a state approved transit district and is considered part of the metered rate.

2. (G) Attendant

   Invalid Coach

   Attendant services may be paid when provided by an employee other than the driver.

3. (H) Assistance

   Livery

   Livery assistance services provided by the driver or another employee may be paid for each recipient assisted. Payment may be made for assistance at either or both the pickup point and drop-off point except assistance from or into a nursing home from a livery vehicle will not be covered. Physically helping a recipient only into or out of the livery vehicle is not considered assistance.

4. (I) Items Included in Fees

   All payment rates include all expenses, including tolls and telephone calls.

5. (J) Private Transportation

   Payment shall be made based on the mileage from the recipient's home to the medical provider.

(j) Rates

Payment is in accordance with the following schedule: