Non-Emergency Medical Transportation

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Date: May 11, 2022
To: Health Plan of San Joaquin (HPSJ) Practitioners, Providers and Facilities
From: Health Plan of San Joaquin
Subject: Non-Emergency Medical Transportation
Business: Medi-Cal Managed Care

Non-emergency medical transportation (NEMT) is available for a member with a medical
and/or physical condition that makes transportation by ordinary public or private transportation medically contraindicated, and transport is needed to obtain medical care. NEMT must be prescribed in writing by the member’s treating Physician, Physician Assistant or Certified Nurse Midwife and be accompanied by a completed Physician Certification Form (PCS).

Additional guidance is provided to you on page two for your review prior to
submitting an NEMT request. Please post these requirements in your office for staff to
review and reference.

A PCS overview will be provided at the lunch and learn, scheduled for June 8, 2022, please visit https://www.hpsj.com/alerts/ to learn more!

If you have any further questions, please contact your Provider Services Representative, or call our Customer Service Department at 1-888-936-PLAN (7526). You may also visit https://www.hpsj.com/alerts/ for online access to the documents shared.

Additional Non-Emergency Medical Transportation guidance:

A. For non-emergency transportation, if a member’s medical and physical condition
requires any of the following, then the member requires NEMT:

  1. Supine or prone position
  2. Member incapable of sitting in a private vehicle, taxicab, or other form of public transportation for the time necessary to transport to and from their appointment.
  3. The member needs to be transported in a wheelchair or assisted to and from their residence, a vehicle and a place of treatment because of disabling physical or mental limitation.

B. If a member’s medical and physical condition does not require any of the above, then the member requires NMT.

C. Transportation Authorization:

  1. All non-emergent medical transportation and air ambulance requires a Physician Certification Statement (PCS) form indicating the appropriate level of service for the member. For non-emergent transportation, HPSJ will approve the lowest level of medical transportation that is adequate for the member’s medical need and is available at the time the transportation is required. Once the member’s treating physician prescribes the form of transportation, HPSJ cannot modify the authorization. No authorization is required for emergency transportation.
  2. HPSJ and its network providers shall follow DHCS contractual standards for timely access to care.
  3. Authorization for non-emergent air ambulance, ambulance, litter van, and wheelchair van are determined by the Medical Management Department. Denials can only be made by the Medical Director or his/her designee.

D. All NEMT PCS forms must include, at a minimum, the components listed below:

  1. Function Limitations Justification: For NEMT, the physician is required to document the member’s limitations and provide specific physical and medical limitations that preclude the member’s ability to reasonably ambulate without assistance or be transported by public or private vehicles.
  2. Dates of Service Needed: Provide start and end dates for NEMT services; authorizations may be for a maximum of 12 months.
  3. Mode of Transportation Needed: List the mode of transportation that is to be used when receiving these services (ambulance/gurney van, litter van, wheelchair van or air transport).
  4. Certification Statement: Prescribing physician’s statement certifying that medical necessity was used to determine the type of transportation being requested.

If you have questions, please contact the Provider Services team at 1.888.936.PLAN (7526).

Posted on May 11th, 2022

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