Ohio Admin. Code 5160-15-27 - Transportation: services from an eligible provider: documentation

(A) Certification is required needed to confirm the necessity of wheelchair van services and most non-emergency ambulance services. No certification is required needed for transportation services furnished by an eligible provider that are automatically deemed to be necessary in accordance with rule 5160-15-22, 5160-15-23, or 5160-15-24 of the Administrative Code. A managed care plan (MCP) medicaid managed care organization (MCO) is not required obliged to use the practitioner certification process described in paragraph (B) of this rule to certify the necessity of a transportation service furnished to a medicaid-eligible individual enrolled in the MCP MCO.

(B) For transportation services that require need certification but are not furnished to a medicaid-eligible individual enrolled in an MCP MCO, a practitioner certification form is used.

(1) The nature of the practitioner certification form depends on the type of transportation service.

(a) For wheelchair van services, an ODM 03452, "Certification of Necessity for Transportation by Wheelchair Van" (07/2015), must be is used.

(b) For non-emergency ground ambulance services, documents required by the primary payer of the claim are acceptable; if medicaid is the primary payer, then an ODM 01960, "Certification of Necessity for NonEmergency Transportation by Ground Ambulance" (07/2015), must be is used.

(c) For air ambulance services, any document that includes the information specified in paragraph (B)(1)(b) of rule 5160-15-24 of the Administrative Code is acceptable.

(2) If practitioner certification for a transportation service is required needed, then the transportation provider must obtain obtains a completed, signed, and dated practitioner certification form before submitting a claim.

(a) The date shown on the form must be is the actual date of signature.

(b) The date of signature must be not cannot be more than one hundred eighty days after the latter of two dates:

(i) The first date of service; or

(ii) The date on which the transportation provider learns of the individual's medicaid eligibility.

(c) In no case does the date of signature on the practitioner certification form extend the limits specified in Chapter 5160-1 of the Administrative Code for the timely filing of claims.

(d) Persons who sign on behalf of the certifying practitioner, with proper authority or the approval of the certifying practitioner, must include are to add the practitioner's name as well as their own signature and professional designation (e.g., such as MD, DO, DPM, RN, APN, PA, LSW).

(e) The certification must not create a conflict of interest for the practitioner.

(f) (e) A photocopy, an electronic copy, or a facsimile transmittal of the completed, signed, and dated practitioner certification form is as valid as the original for documentation purposes.

(3) Certification cannot create a conflict of interest for the practitioner. No person employed by, under contract with, serving in a volunteer capacity for, or otherwise associated with a transportation provider can certify the necessity of a service furnished by that provider.

(3) (4) A transportation provider may submit a claim to the Ohio department of medicaid (ODM) for a specific one-way or round-trip transport after having obtained an incomplete practitioner certification form if the following conditions apply:

(a) The transportation provider has made three attempts to obtain the completed form;

(b) The transportation provider has allowed no fewer than thirty calendar days for receipt of a reply after each attempt; and

(c) The transportation provider has received no response from the practitioner.

(4) (5) For wheelchair van services and non-emergency ground ambulance services, a practitioner may designate one of two certification periods, each of which begins on the earlier of the date of signature or the first date of service:

(a) Temporary certification for up to ninety days; or

(b) Ongoing certification for one year.

(5) (6) If a change in a medicaid-eligible individual's status renders the current practitioner certification form obsolete, then a new form is required to be completed.

(6) (7) No payment is to be made for transportation services provided during the certification period that do not meet the certification criteria. For example, payment cannot be made for a transport by wheelchair van provided during the certification period if no mobility device is involved.

(7) (8) A patently incorrect practitioner certification form is invalid, even if it is signed.

(8) (9) False certification constitutes medicaid fraud. The following examples illustrate false certification:

(a) For transport by wheelchair van, certification that a medicaid-eligible individual must be accompanied by a mobility device is false if the medicaid-eligible individual in fact has no need for and never uses a mobility device.

(b) For non-emergency transport by ground ambulance, certification that a medicaid-eligible individual requires medical treatment or continuous supervision by an EMT during transport is false if such treatment or supervision could reasonably and appropriately be supplied by someone who has not had training to the level of an EMT.

(9) (10) Certification is not transferrable between medicaid-eligible individuals or transportation providers.

(C) Each transportation provider must is expected to maintain documentation that fully accounts for the services provided. No payment is to be made for a service if the for which a transportation provider fails to obtain the required necessary documentation before submitting a claim to the department ODM or to an MCP MCO. All records and documentation required by this rule must be retained in accordance with related to transportation services are subject to retention provisions set forth in Chapter 5160-1 of the Administrative Code.

(D) Each transportation provider must is to maintain the following records:

(1) Copies of all certification or licensure documents required for crew members and attendants, which must be current at the time of the transport;

(2) Completed practitioner certification forms, when applicable;

(3) Copies of completed requests for manual review, when applicable;

(4) The relevant trip information specified in agency 4766 of the Administrative Code; and

(5) The following medicaid-specific trip information:

(a) Identification of the particular vehicle used;

(b) The name of each wheelchair van attendant, when applicable;

(c) The medicaid identification number of each medicaid-eligible individual; and

(d) For non-emergency trips, the signature of each medicaid-eligible individual transported.

(E) If a transportation provider fails to produce documentation requested by the department ODM or an MCP MCO to substantiate compliance with any provision in this chapter, then the department ODM may terminate or deny reinstatement of the medicaid provider agreement in accordance with Chapter 5160-1 rule 5160-1-17.6 of the Administrative Code and may seek repayment for undocumented services.

Notes

Ohio Admin. Code 5160-15-27

Effective: 7/1/2021
Five Year Review (FYR) Dates: 4/16/2021 and 07/01/2026
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02
Prior Effective Dates: 04/07/1977, 12/21/1977, 12/30/1977, 12/03/1981, 08/15/1982, 05/09/1986, 12/01/1990, 05/01/1992 (Emer.), 08/13/1992, 07/05/1993, 01/01/1994, 04/01/1994, 10/01/1997, 03/01/2000, 12/27/2001, 12/31/2001, 10/01/2003, 12/30/2005 (Emer.), 03/27/2006, 04/01/2016