Updated Physician Certification Form (PCS) – Request for Transportation for Non-Emergency Medical Transportation (NEMT)

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Date: January 25, 2023
To: Health Plan of San Joaquin (HPSJ) Practitioners, Provider and Facilities
From: HPSJ Practitioners, Providers and Facilities
Type: Informational/Educational
Subject: Updated Physician Certification Form (PCS) – Request for Transportation for Non-Emergency Medical Transportation (NEMT)
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).

As of 3/1/2023, HPSJ will only accept the updated Physician Certification Form (PCS) – Request for Transportation. The updated PCS form can be downloaded at, https://www.hpsj.com/forms-documents/.

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

Additional Non-Emergency Medical Transportation guidance:

    1. 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.
    2. If a member’s medical and physical condition does not require any of the above, then the member requires Non-Medical Transportation (NMT).
    3. Transportation Authorization:
      1. No authorization is required for emergency transportation.
      2. All non-emergency medical transportation requires a Physician
        Certification Statement (PCS) form indicating the appropriate level of service/transport 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.
      3. HPSJ and its network providers shall follow the DHCS contractual standards for timely access to care.
      4. Authorization for non-emergency medical transport (air ambulance, ambulance, litter van, and wheelchair van) is determined by the Medical Management Department. Denials can only be made by the Medical Director or his/her designee.
    4. All NEMT PCS forms must include, at a minimum, the components listed below:
      1. Function Limitations Justification: 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; 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.
      5. The certification statement must be signed by a physician or a physician extender, such as a dentist, podiatrist, mental health provider, or substance use disorder provider.

To learn more, please view the Non-Emergency Medical and Non-Medical Transportation Services and Related Travel Expenses Frequently Asked Questions (FAQs):

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.

Posted on January 25th, 2023