Health, Department of

Medicaid

Chapter 36: Administrative Transportation

Effective Date: 06/18/1996 to 02/16/2005

Rule Type: Superceded Rules & Regulations

Reference Number: 048.0037.36.06181996

WYOMING MEDICAID RULES

CHAPTER 36

ADMINISTRATIVE TRANSPORTATION

Section 1. Authority

This Chapter is promulgated by the Department of Health pursuant to the Medical Assistance and Services Act at W.S. 42-4-101 et seq. and the Wyoming Administrative Procedures Act at W.S. 16-3-101 et seq.

Section 2. Purposes and Applicability

This Chapter establishes the scope of administrative transportation covered by Medicaid and the methods and standards of reimbursing for such services.

Section 3. General terms

(a) This rule shall apply to and govern the provision of administrative transportation and reimbursement for those services.

(b) The Department may issue Manuals or Bulletins to providers and/or other affected parties to interpret the provisions of this rule. Such Manuals and Bulletins shall be consistent with and reflect the policies contained in this rule. The provisions contained in Manuals or Bulletins shall be subordinate to the provisions of this Chapter.

Section 4. Definitions

(a) 'Administrative transportation.' Transportation, other than transportation in an ambulance, to and/or from a provider of covered services.

(b) 'Ambulance.' An ambulance as defined by Chapter 15, which definition is incorporated by this reference.

(c) 'Appropriate provider.' A provider that offers services sufficient to meet the medical needs of a patient.

(d) 'Chapter I.' Chapter I, Rules for Medicaid Administrative Hearings, of the Wyoming Medicaid Rules.

(e) 'Chapter 3.' Chapter 3, Provider Participation, of the Wyoming Medicaid Rules.

(f) 'Chapter 6.' Chapter 6, HEALTH CHECK (EPSDT) SERVICES, of the Wyoming Medicaid Rules.

(g) 'Chapter 15.' Chapter 15, Ambulance Services, of the Wyoming Medicaid Rules.

1. (h) 'Chapter 26.' Chapter 26, Covered Services, of the Wyoming Medicaid Rules.
2. (i) 'Chapter 37.' Chapter 37, Fiscal Responsibility, of the Wyoming Medicaid Rules.
3. (j) 'Claim.' A request by a recipient for reimbursement for administrative transportation.
4. (k) 'Covered services.' Services which are Medicaid reimbursable pursuant to the rules of the Department.
5. (l) 'Department.' The Wyoming Department of Health, its agent, designee or successor.
6. (m) 'Department of Family Services (DFS).' The Wyoming Department of Family Services, its agent, designee or successor.
7. (n) 'Department of Transportation (DOT).' The Wyoming Department of Transportation, its agent, designee or successor.
8. (o) 'Division.' The Division of Health Care Financing of the Department, its agent, designee or successor.
9. (p) 'Emergency.' An emergency as defined by Chapter 15, which definition is incorporated by this reference.
10. (q) 'Excess payments.' Medicaid funds received by a provider or recipient which exceed the reimbursement limits established by this Chapter.
11. (r) 'Expanded services.' 'Expanded services' as defined by Chapter 6, which definition is incorporated by this reference.
12. (s) 'In-town.' Within the city limits of an incorporated city or town.
13. (t) 'Local agency.' The County office of the DFS, its agent, designee or successor.
14. (u) 'Local trade area.' The geographic area surrounding the recipient's residence, excluding portions of states other than Wyoming, that is commonly used by other persons in the same area to obtain similar services.
15. (v) 'Medicaid.' Medical assistance and services provided pursuant to Title XIX of the Social Security Act and the Wyoming Medical Assistance and Services Act.
16. (w) 'Medicaid reimbursement.' The maximum Medicaid reimbursement for administrative transportation as specified by this Chapter.
17. (x) 'Medical appointment.' A scheduled appointment with a provider.
18. (y) 'Medical necessity' or 'medically necessary.' A service that is required to diagnose, treat,

cure or prevent an illness, injury or disease which has been diagnosed or is reasonably suspected, to relieve pain, or to improve and preserve health and be essential to life. The service must be:

(i) Consistent with the recipient’s diagnosis and treatment of the recipient’s condition;

(ii) In accordance with the standards of good medical practice among the provider’s peer group;

(iii) Required to meet the medical needs of the recipient and undertaken for reasons other than the convenience of the recipient and the provider; and

(iv) Provided in the most appropriate and cost-effective setting required by the recipient’s condition.

“Nursing facility.” “Nursing facility” as defined by 42 U.S.C. § 1396r(a), which is incorporated by this reference.

“Physician.” A person licensed to practice medicine or osteopathy by the Wyoming State Board of Medical Examiners or a similar agency in another state.

“Prior authorized.” Approval by the Department pursuant to the prior authorization provisions of Chapter 3, which are incorporated by this reference.

“Provider.” A provider as defined by Chapter 3, which definition is incorporated by this reference.

“Recipient.” An individual that has been determined eligible for Medicaid.

“Recipient under age twenty-one.” An individual under age twenty-one that has been determined eligible for Medicaid. A recipient is under age twenty-one before or during the month in which he or she turns twenty-one years of age.

(ff) 'Service area.” The State of Wyoming and the following cities or towns: Craig, Colorado; Idaho Falls, Montpelier and Pocatello, Idaho; Billings and Bozeman, Montana; Kimball and Scottsbluff, Nebraska; Belle Fourche, Custer, Deadwood, Rapid City and Spearfish, South Dakota; and Ogden and Salt Lake City, Utah.

“Services.” Health services or supplies.

“Subsidized public transportation.” Public transportation carriers that receive a subsidy from the Department of Transportation.

“Travel consent.” A document, in the form specified by the Department, that contains:

(i) An itemized statement of the particulars of the administrative transportation for which a recipient is requesting reimbursement; and (ii) The original signature of the recipient or other payee that receives the reimbursement.

(jj) 'Urgent case.' A situation, other than an emergency, where a recipient requires the immediate care of a provider.

(kk) 'Usual and customary charges.' The charges for comparable transportation or other services provided to non-recipients.

(ll) 'Working day.' 8:00 a.m. to 5:00 p.m., Mountain Time, Monday through Friday, excluding State holidays.

(mm) 'Wyoming Rural Transit Program.' The transportation program operated by the Wyoming Department of Transportation.

Section 5. Provider participation.

(a) Contract with DFS. Any individual or entity that wishes to receive Medicaid reimbursement for furnishing covered services to recipients must enter into a contract with DFS to provide administrative transportation.

(b) Compliance with Chapter 3. An individual or entity that wishes to receive Medicaid reimbursement for furnishing covered services to recipients must meet the provider participation requirements of Chapter 3, which requirements are incorporated by this reference.

Section 6. Reimbursable transportation expenses.

(a) Ambulance transportation. Transportation in an ambulance is a covered services as specified in Chapter 15.

(b) General rule. Administrative transportation to and/or from a medical appointment is reimbursable if:

(i) The covered services furnished to the recipient at the medical appointment are medically necessary;

(ii) Transportation has been approved by the local agency at least three working days in advance of the necessary transportation; and

(iii) The transportation is via the least costly mode of transportation selected and approved by the local agency pursuant to subsection (c).

(c) Selection and approval of administrative transportation.

(i) The local agency shall be responsible for selecting and approving the mode of administrative transportation.

(ii) In selecting and approving transportation, the local agency:

(A) May consider the following modes of transportation:

(I) Public transportation, including subsidized public transportation and the Wyoming Rural Transit Program;

(II) Private automobile;

(III) Taxi;

(IV) Bus;

(V) Shuttle services; and

(VI) Airline; and

(B) Shall select the least expensive mode of transportation that is reasonably available.

(iii) Per diem expenses. Per diem expenses are reimbursable to a recipient or a recipient’s legal guardian if:

(A) The individual who is to receive services is a recipient under age twenty-one; and

(B) The services to be received are expanded services.

(d) Transportation in-town is reimbursable if:

(i) Necessary to obtain HEALTH CHECK services pursuant to Chapter 6; or

(ii) Necessary in an urgent case.

(e) Transportation to medical appointments outside Wyoming and within the service area is reimbursable if:

(i) The covered service is not available in the local trade area; and

(ii) The specified city within the service area is closer (in highway miles) than the nearest location within Wyoming where the service is available.

(f) Transportation to medical appointments outside the service area is not reimbursable unless:

(i) A physician has referred the recipient to a specified provider for covered services that are not available in the service area; and (ii) The referral is in writing and the medical necessity of the referral is documented in the recipient's medical records.

Section 6. Excluded transportation expenses. The following transportation expenses are not reimbursable:

1. (a) Transportation to receive services which are not covered services;
2. (b) Transportation of a family-member or friend to visit a recipient or consult with the recipient's physician or other provider of medical services, unless the transportation is to visit a recipient under age twenty-one and the visit is medically necessary;
3. (c) Transportation to pick up pharmaceuticals;
4. (d) Transportation of a resident of a nursing facility to receive services that are available at the nursing facility;
5. (e) Transportation of a recipient in response to detention ordered by a court or law enforcement agency;
6. (f) Transportation based on a physician's standing orders;
7. (g) Transportation to receive covered services from a provider because another provider has denied services to the recipient due to the recipient's refusal to follow medical advise/or the recipient's unacceptable conduct.
8. (h) Missed appointments. If a recipient misses or cancels a medical appointment for which Medicaid reimbursement has been paid pursuant to this rule, the recipient must refund the funds to the local agency within fifteen days of the missed appointment (unless the medical appointment has been rescheduled). Medicaid funds that are not timely refunded shall be considered excess payments and may recovered pursuant to Section 10.

Section 7. Procedures for obtaining reimbursement.

1. (a) Request for reimbursement. A recipient that wishes to receive reimbursement for administrative travel must contact the local agency and make a request. The request may be oral or written, and the recipient shall furnish information as requested by the local agency and complete whatever documentation is required by the local agency.
2. (b) Payment. Payment shall be by warrant issued to the recipient or other payee.
3. (c) Travel consent. At the time a recipient or other payee receives reimbursement for administrative transportation, the recipient or payee must sign a travel consent and return it to DFS. Travel consents shall become part of the recipient's file and retained by DFS.

Section 8. Prior authorization.

(a) Incorporation of Chapter 3. Prior authorization of administrative transportation shall be governed by the prior authorization requirements of Chapter 3, which are incorporated by this reference.

(b) Services that require prior authorization.

(i) The Division may, from time to time, designate administrative transportation that requires prior authorization.

(ii) In designating administrative transportation that requires prior authorization, the Division shall consider the:

(A) Cost of the transportation; (B) Potential for over-utilization of the transportation; and (C) Availability of lower cost alternatives.

(iii) The Division shall disseminate a list of administrative transportation services that require prior authorization to providers through Manuals or Bulletins.

(iv) The failure to obtain prior authorization shall result in denial of Medicaid payment for the service.

Section 9. Allowable Medicaid reimbursement.

(a) Generally. Medicaid reimbursement for administrative transportation shall be as follows:

(i) Reimbursement to a recipient: (A) Prospective reimbursement. The recipient's projected expenses. (B) Retroactive reimbursement. The recipient's actual expenses.

(ii) Reimbursement to a provider. The lesser of the charge to the recipient and the usual and customary charge for the transportation.

(b) Private automobile. Medicaid reimbursement for administrative transportation furnished in a private automobile shall be:

(i) Based on map mileage using major highways; (ii) Limited to ten (10) cents per mile; and (iii) Shall not be paid for fractions of a mile.

(c) Per diem expenses. Medicaid reimbursement for per diem expenses is limited to $20.00 per day, to be used for meals and lodging.

(d) Retrospective reimbursement. Reimbursement for administrative transportation that is already completed is reimbursable if:

(i) Requested within thirty days after the date the travel was completed and is approved; and

(ii) The request contains the information and documentation required by the local agency, including a valid receipt for the expenses of the travel.

Section 10. Recovery of excess payments. Excess payments may be recovered pursuant to the recovery of excess payments provisions of Chapter 3, which are incorporated by this reference.

Section 11. Reconsideration.

(a) Request for reconsideration. A provider may request that the Department reconsider a decision to recover excess payments or deny payments. Such request must be mailed to the Department by certified mail, return receipt requested within twenty days of the date the provider notice of the action. The request must state with specificity the reasons for the request. Failure to provide such a statement shall result in the dismissal of the request with prejudice.

(b) Reconsideration. The Department shall review the decision and send written notice by certified mail, return receipt requested, to the provider of its final decision within forty-five days after receipt of the request for reconsideration or the receipt of any additional information requested pursuant to (c), whichever is later.

(c) Request for additional information. The Department may request additional information from the provider as part of the reconsideration process. Such a request shall be made in writing by certified mail, return receipt requested. The provider must provide the requested information within thirty days after the date of the request. Failure to provide the requested information shall result in the dismissal of the request with prejudice.

(d) Reconsideration shall be limited to whether the Department has complied with the provisions of this Chapter.

(e) Informal resolution. The provider or the Department may request an informal meeting before the final decision on reconsideration to determine whether the matter may be resolved. The substance of the discussions and/or settlement offers made pursuant to an attempt at informal resolution shall not be admissible as part of a subsequent administrative hearing or judicial proceeding.

(f) Failure to request reconsideration. A provider which fails to request reconsideration pursuant to this section may not subsequently request an administrative hearing regarding the recovery of excess payments pursuant to Chapter I.

Section 12. Administrative hearing.

(a) Providers. A provider may request an administrative hearing regarding the final decision pursuant to Chapter I of these rules by mailing by certified mail, return receipt requested or personally delivering a request for hearing to the Department within twenty days of the date the provider receives notice of the final decision pursuant to Section 11.

(b) Recipients. A recipient may request an administrative hearing regarding the final decision pursuant to Chapter I of these rules by mailing or personally delivering a request for hearing to the Department within thirty days of the date the recipient receives notice of the decision to deny payment or recover excess payments.

Section 13. Superseding effect. When promulgated, this Chapter supersedes all prior rules or policy statements issued by the Department, including provider manuals and provider bulletins, which are inconsistent with this Chapter.

Section 14. Subject to Chapter 37. This Chapter is subject to Chapter 37.

Section 15. Severability. If any portion of this Chapter is found to be invalid or unenforceable, the remainder shall continue in full force and effect.