016.05.18 Ark. Code R. 001
Non-emergency medical transportation will be provided by the transportation broker for the region in which the beneficiary lives with the exception of transportation to and from an Early Intervention Day Treatment (EIDT) or an Adult Developmental Day Treatment (ADDT) center when the transportation is provided by the EIDT or ADDT facility.
Transportation provided by an EIDT or ADDT transportation providers is a covered service only for Medicaid eligible beneficiaries who are being transported to and from an EIDT or ADDT facility. Transportation by an EIDT or ADDT of Medicaid beneficiaries to and from other medical providers is not covered.
The Medicaid Program covers EIDT or ADDT transportation for "loaded miles" only. For purposes of this manual, "loaded miles" is that part of the trip in which a Medicaid beneficiary is a passenger in an EIDT or ADDT vehicle and is being transported either from the point of pickup to the facility or from the facility to the point of delivery. The exact address where the beneficiary is picked up and delivered must be documented in the EIDT or ADDT transportation provider's records.
If more than one Medicaid beneficiary is transported at the same time to the same location, Medicaid may be billed only for one beneficiary. If more than one Medicaid beneficiary is transported at the same time to different locations, the provider may bill only for the beneficiary traveling the farthest distance, (For purposes of this manual, the farthest distance means the beneficiary on the route who lives the farthest away from the facility.)
The provider must keep a record of all persons being transported. If the person is a Medicaid beneficiary, the beneficiary's Medicaid identification number must also be recorded in the provider's records. The provider must complete the EIDT/ADDT Transportation Log (Form DMS-638) each time a client is transported to or from the facility. View or print EIDT/ADDT Transportation Log Form DMS-638.
Mileage calculation is based on the odometer mileage for the Medicaid beneficiary traveling the farthest distance. The odometer mileage will be determined based on the following:
The route taken when transporting the clients must be reasonable and must be planned to minimize the beneficiaries' time spent in route to and from the facility (i.e.. must pick up the beneficiary farthest from the facility first and drop him or her off last). The provider must not take unnecessary extended routes to increase the mileage.
See Section 290.000 of this manual for billing procedures.
EIDT and ADDT transportation providers must maintain all required records for a period of five (5) years from the last date of service or until all audit questions, appeal hearings, investigations or court cases are resolved, whichever is longer. The records must be made available during normal business hours to authorized representatives of the Arkansas Department of Human Services, Arkansas Division of Medical Services, the State Medicaid Fraud Unit, and representatives of the Department of Human Services and its authorized agents or officials. Failure to furnish records upon request will result in sanctions being imposed.
All documentation must be made available to representatives of the Division of Medical Services at the time of an audit by the Medicaid Field Audit Unit. All documentation must be available at the provider's place of business. If an audit determines that recoupment is necessary, there will be no more than thirty (30) days after the date of the recoupment notice in which additional documentation will be accepted.
Prior Authorization is not applicable to Transportation Services provided by EIDT or ADDT providers in Arkansas.
Providers
The Medicaid Program reimburses the lesser of the billed charges or the Title XIX maximum allowable. EIDT and ADDT Transportation providers are reimbursed on the basis of a rate times loaded miles traveled for the eligible Medicaid beneficiary transported the longest distance for each trip.
EIDT and ADDT transportation providers are required to prepare and submit an annual EIDT/ADDT Survey (View or print EIDT/ADDT Transportation Survey DMS-632) and other applicable information concerning the survey to the Arkansas Department of Human Services Division of Medical Services, Provider Reimbursement Unit. View or print the Arkansas Department of Human Services Division of Medical Services. Provider Reimbursement Unit contact information.
The survey information will be reported for the provider's fiscal period. The survey must be submitted within five {5) months after the close of the provider's fiscal year end. Providers with financial reporting periods of less than six (6) months are not required to submit a survey. However, if no survey is required, the provider must notify the Division of Medical Services (DMS) in writing why the survey is not being submitted. Failure to submit the completed survey or failure to submit a written explanation of a reporting period of less than six (6) months within the prescribed period, except as expressly extended by the State Medicaid agency, may result in the suspension of reimbursement until DMS receives this information.
Survey information requested includes direct and indirect/overhead costs, revenues and client mileage information associated with and applicable to the EIDT or ADDT Transportation Program. No other program costs, revenues or mileage information is to be included on the survey. If the provider provides transportation services for programs other than EIDT or ADDT programs, please remove the other program costs, revenues and mileage information before completing the survey and submit a narrative describing how these other transportation program amounts were calculated and removed. All cost and revenue amounts are to be reported using the accrual method of accounting and will be reported in whole dollar amounts, no cents.
Providers must also submit with the survey a written general description of what costs are included with indirect/overhead costs and how these costs were identified, calculated and allocated to the EIDT or ADDT transportation program.
Providers are required to maintain adequate financial records, mileage data and rider data for proper documentation and support of the cost and statistical information reported on the annual survey. These records must be retained for a period of five years after submission of the survey. The surveys, supporting documentation and provider narratives are subject to on-site review and inspection by DHS/DMS personnel.
EIDT and ADDT providers may order copies of Form DMS-632 on the Medicaid Form Request. Requests may be forwarded to the Hewlett Packard Enterprise Provider Assistance Center. View or print the DXC Provider Assistance Center contact Information.
EIDT and ADDT transportation providers use the CMS-1500 claim form to bill the Arkansas Medicaid Program on paper for services provided to eligible Medicaid beneficiaries. Each claim should contain charges for only one beneficiary.
Section III of this manual contains information about Provider Electronic Solutions (PES) and other available options for electronic claim submission.
Early Intervention Day Treatment (EIDT) providers and Adult Developmental Day Treatment (ADDT) providers may choose to provide transportation services for their clients as a fee-for-service provider for transportation to and from an EIDT or ADDT facility only. EIDT or ADDT transportation cannot be claimed for transporting beneficiaries to and from other medical providers.
The procedure code A0120 must be used when billing the Medicaid Program for EIDT or ADDT transportation services. The Medicaid Program reimburses for "loaded miles" only, e.g., from the point of pickup to the EIDT or ADDT facility and from the EIDT or ADDT facility to the point of delivery. The route must be planned to minimize each beneficiary's time in route (i.e., the facility must pick up the beneficiary who lives farthest away first and drop him or her off last). One unit equals one mile. The overall allowable one-way mileage for each pickup and delivery trip should be totaled and rounded to a whole mile. Mileage will be rounded up if 0.5 or greater and rounded down if 0.4 or less.
Bill Medicaid for professional services with form CMS-1500. The numbered items in the following instructions correspond to the numbered fields on the claim form. View a sample form CMS-1500.
Carefully follow these instructions to help the Arkansas Medicaid fiscal agent efficiently process claims. Accuracy, completeness, and clarity are essential. Claims cannot be processed if necessary information is omitted.
Forward completed claim forms to the Claims Department. View or print the Claims Department contact information.
NOTE: A provider delivering services without verifying beneficiary eligibility for each date of service does so at the risk of not being reimbursed for the services.
ATTACHMENT 3.I-A
AMOUNT, DURATION AND SCOPE OF SERVICES PROVIDED
Ground Ambulance Services
For transportation of recipient when medically necessary as certified by a physician to a hospital, to a nursing home from the hospital or patient's home, to the patient's home from the hospital or nursing home, from a hospital (after receiving emergency outpatient treatment) to a nursing home if a patient is bedridden, and from a nursing home to another nursing home if determined necessary by the Office of Long Term Care, Emergency service is covered only through licensed emergency ambulance companies. Services not allowed by Title XVI11 but covered under Medicaid will be paid for Medicare/Medicaid recipients.
These services will be equall[GREATER THAN] available to all recipients.
Air ambulance services are provided to Arkansas Medicaid beneficiaries only in emergencies.
Air ambulance providers must be licensed by the Arkansas Ambulance Boards and enrolled as a Title XVIII, Medicare Provider.
EIDT and ADDT providers ma\ provide transportation to and from their facility. The Medicaid transportation broker must provide transportation to and from the nearest qualified medical provider for the purpose of obtaining medical treatment.
Ground Ambulance Services
For transportation of recipients when medically necessary as certified by a physician to a hospital, to a nursing home from the hospital or patient's home, to the patient's home from the hospital or nursing home, from a hospital {after receiving emergency outpatient treatment) to a nursing home if a patient is bedridden and from a nursing home to another nursing home if determined necessary by the Office of Long Term Care. Emergency service is covered only through licensed emergency ambulance companies. Services not allowed by Title XVIII but covered under Medicaid will be paid for Medicare Medicaid recipients
These services will be equally available to all recipients.
Air ambulance services are provided to Arkansas Medicaid beneficiaries only in emergencies.
Air ambulance providers must be licensed by the Arkansas Ambulance Boards and enrolled as a Title XVIII, Medicare Provider.
EDIT and ADDT providers may provide transportation to and from a DDTCS facility. The Medicaid transportation broker must provide transportation to and from the nearest qualified medical provider for the purpose of obtaining medical treatment.
Pediatric Hospitals
Effective for claims with dates or service on or after July 1, 2018, EIDT and ADDT transportation providers will be reimbursed on a per mile basis at the lesser of the billed charges or the maximum Title XIX (Medicaid) charge allowed. Transportation will be covered from the point of pick-up to the EIDT and ADDT facility and from the EIDT and ADDT facility to the point of delivery. If more than one eligible Medicaid recipient is transported at the same time to the same location, Medicaid may be billed only for one recipient. If more than one Medicaid recipient is transported at the same time to different locations, the provider may bill only for the recipient traveling the farthest distance. The route must be planned to ensure that beneficiaries spend the least of time being transported. The maximum per mile is based on reasonable cost.
The EDIT and ADDT transportation providers will submit annual statements of mileage, revenues and expenses, i.e. salaries, repairs, supplies, rent, indirect overhead costs, etc. The State Agency will review the cost and mileage information at least biennially and adjust the reimbursement rate if necessary. Therefore, an inflation factor will not be automatically applied.
016.05.18 Ark. Code R. 001