N.H. Admin. Code § He-W 573.08

Current through Register No. 45, November 7, 2024

Section He-W 573.08 - Documentation

(a) When wheelchair van services are required, a Form 975, "Documentation to Support the Use of Wheelchair Van Services" (May 2014), shall be completed prior to the services being provided, and as follows:

(1) The wheelchair van provider shall complete section 1 of the form by providing information specific to the wheelchair van provider;

(2) The recipient's treating physician, doctor of osteopathic (DO), physician assistant (PA), advanced practice registered nurse (APRN), or registered nurse (RN) shall complete section 2 of the form and certify by signature that the services are necessary; and

(3) When submitting a request for a service limit override, the wheelchair van provider shall complete section 3 of the form, and submit the form in accordance with He-W 573.10 below.

(b) Wheelchair van service providers shall obtain and retain copies of the signed and completed Form 975 "Documentation to Support the Use of Wheelchair Van Services" (May 2014), and provide copies of said documentation upon request to the department or the MFCU.

(c) Wheelchair van service providers shall retain, and provide when requested by the department or MFCU, copies of the trip logs, which shall contain the following documentation for each trip:

(1) Origin;

(2) Destination;

(3) Date of service;

(4) Driver's name;

(5) Time of pick-up and drop off;

(6) Whether the trip was one-way or round-trip;

(7) Amount of wait time if applicable;

(8) Loaded mileage incurred; and

(9) Names and number of recipients transported concurrently during each trip.

(d) Wheelchair van service providers shall retain, and provide when requested by the department or MFCU, the following documentation concerning the safety of wheelchair vans used for transporting recipients:

(1) Proof that the vehicle was registered in accordance with RSA 261:40 and inspected in accordance with RSA 266:1, during the time of medicaid wheelchair van service; and

(2) Proof of insurance in accordance with He-W 573.07(b) during the time period that services were delivered.

N.H. Admin. Code § He-W 573.08

(See Revision Note at chapter heading He-W 500); ss by #6598, eff 10-8-97; ss by #8401, INTERIM, eff 8-20-05, EXPIRES: 2-16-06; ss by #8563, eff 2-7-06

Amended byVolume XXXIV Number 24, Filed June 12, 2014, Proposed by #10605, Effective 5/23/2014, Expires 5/23/2024.