N.H. Admin. Code § He-W 574.09

Current through Register No. 45, November 7, 2024

Section He-W 574.09 - Extenuating Circumstances

(a) Notwithstanding He-W 574.04(d) and (e) , respectively, the department shall allow general medical transportation reimbursement payments under the following conditions and in accordance with this section:

(1) The recipient found it necessary to take more than one trip per day; and

(2) The point of origin of the medical transportation is not the recipient's residence.

(b) The recipient shall provide following documentation when the recipient found it necessary to take more than one trip in a day:

(1) The recipient's name and address;

(2) The recipient's medicaid identification number; and

(3) Either:

a. A letter from the medicaid enrolled provider which includes details regarding the necessity of the second trip sufficient to enable the department to understand the necessity of the second trip; or

b. A letter from the medicaid enrolled provider which includes details regarding a referral made to another medicaid enrolled provider who was able to see the recipient the same day.

(c) The recipient shall provide following documentation when the point of origin is not the recipient's address:

(1) The recipient's name and address;

(2) The recipient's medicaid identification number; and

(3) Either:

a. A statement, signed by the recipient and the medicaid enrolled provider, containing sufficient detail to enable the department to understand the need for medical or dental services and why the point of origin was not the recipient's residence; or

b. If the recipient must provide care for another party at the residence of the other party, and this is the reason why the transportation was not the recipient's residence:

(i) A statement from the other party's medicaid enrolled provider of the necessity of and the amount of time of the care provided by the recipient for the other party; and

(ii) A statement, signed by the recipient and the recipient's medicaid enrolled provider, containing sufficient detail to enable the department to understand that the need for medical or dental services.

N.H. Admin. Code § He-W 574.09

(See Revision Note at chapter heading He-W 500); ss by #6163, eff 1-4-96, EXPIRED: 1-4-04

New. #8732, eff 9-30-06

Amended byVolume XXXV Number 18, Filed May 7, 2015 , Proposed by #10810, Effective 4/9/2015, Expires4/9/2025.