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Part 32      SOONERRIDE NON-EMERGENCY TRANSPORTATION

317:30-5-325.[RESERVED]
[RESERVED]

317:30-5-326.Provider eligibility
[Revised  01-02-09]
The Oklahoma Health Care Authority (OHCA) is responsible for assuring that necessary transportation is available to all eligible SoonerCare members who are in need of SoonerCare medical services in accordance with 42 CFR 431.53. The agency contracts with a broker to provide statewide curb to curb coverage for non-emergency transportation under the SoonerRide program. The broker provides the most appropriate and least costly mode of transportation necessary to meet the individual needs of SoonerCare members. Payment for covered services to the broker is made pursuant to the methodology described in the Oklahoma Title XIX State Plan. The agency contracts directly with ambulance and air providers for all other transportation needs for eligible members not approved by SoonerRide.
317:30-5-326.1.Definitions
[Revised 06-25-12]
The following words and terms, when used in this subchapter shall have the following meaning, unless context clearly indicates otherwise.
"Attendant" means an employee of the nursing facility who is provided by and trained by the nursing facility at the nursing facility's expense.
"Emergency" means a serious situation or occurrence that happens unexpectedly and demands immediate action such as a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected, by a reasonable and prudent layperson, to result in placing the members' health in serious jeopardy, serious impairment to bodily function, or serious dysfunction of any bodily organ or part.  
"Medical escort" means a family member, legal guardian, or volunteer whose presence is required and medically necessary to assist a member during transport and while at the place of treatment. A medical escort voluntarily accompanies the member during transport and leaves the vehicle at its destination and remains with the member. A medical escort must be of an age of legal majority recognized under State law.
"Member/eligible member" means any person eligible for SoonerCare and individuals considered to be Medicare/SoonerCare full dually eligible. This does not include those individuals who are categorized only as Qualified Medicare Beneficiaries(QMB), Specified Low Income Medicare Beneficiaries (SLMB), Qualifying Individuals-1(QI-1), individuals who are in an institution for mental disease (IMD), inpatient, institutionalized, Home and Community Based Waiver members, with the exception of the In-home Supports Waiver for Children, the Advantage Waiver, the Living Choice demonstration, the Sooner Seniors Waiver, the My Life; My Choice Waiver and the Medically Fragile Waiver.
"Nearest appropriate facility" means a medical facility that is generally equipped and legally permitted to provide the needed care for the illness or injury involved that is the closest in geographical proximity to the members' residence with exceptions. In the case of approved hospital services, it also means that a physician or physician specialist is available to provide the necessary care required to treat the member's condition. The fact that a particular physician does or does not have staff privileges in a hospital is not a consideration in determining whether the hospital has appropriate facilities.  Thus, non-emergency transportation service to a more distant hospital, clinic, practitioner or physicians' office solely to avail a member of the service of a specific physician or physician specialist does not make the institution in which the physician has staff privileges the nearest institution with appropriate facilities.
"Non-ambulance" means a carrier that is not an ambulance.
"Non-emergency" means all reasons for transportation that are not an emergency as defined above.
"SoonerRide Non-Emergency Transportation (NET)" means non-emergency non-ambulance transportation provided statewide within the geographical boundaries of the State of Oklahoma.
317:30-5-327.Eligibility for SoonerRide NET

[Revised 09-01-15] 
   Transportation is provided when medically necessary in connection with examination and treatment to the nearest appropriate facility in accordance with 42 CFR 440.170. As the Medicaid Agency, the Oklahoma Health Care Authority (OHCA) is the payer of last resort, with few exceptions.  When other resources are available, those resources must first be utilized. Exceptions to this policy are those receiving medical treatment through Indian Health Services and those eligible for the Crime Victims Compensation Act. Individuals considered fully dual eligible qualify for SoonerRide. However, SoonerRide excludes those individuals who are categorized as:

(1) Qualified Medicare Beneficiaries(QMB);

(2) Specified Low Income Medicare Beneficiaries (SLMB) only;

(3) Qualifying Individuals-1 and individuals who are in an institution for mental disease (IMD);

(4) inpatient;

(5) institutionalized;
(6) Home and Community Based Waiver members, with the exception of the In-home Supports Waiver for Children, the Advantage Waiver, the Living Choice demonstration, and the Medically Fragile Waiver.

317:30-5-327.1.SoonerRide NET Coverage
[Revised 09-01-15]

(a) SoonerRide NET is available for SoonerCare covered admission and discharge into inpatient hospital care, outpatient hospital care, services from physicians/approved practitioners, diagnostic services, clinic services, pharmacy services, eye care and dental care under the following conditions:

(1) Transportation is to the nearest appropriate facility or medical provider capable of providing the necessary services.

(A) The nearest appropriate facility or provider is not considered appropriate if the member's condition requires a higher level of care or specialized services available at the more distant facility.  However, a legal impediment barring a member's admission would mean that the institution did not have "appropriate facilities".  For example, the nearest transplant center may be in another state and that state's law precludes admission of nonresidents.

(B) The nearest appropriate facility is not considered appropriate if no bed or provider is available. However, the medical records must be properly documented.

(C)  Services should be available within 45 miles of the members' residence with exceptions. The OHCA has discretion and the final authority to approve or deny travel greater than 45 miles to access services.

(i) Members seeking self-referred services are limited to the 45 mile radius.

(ii) Native Americans seeking services at a tribal or I.H.S facility may be transported to any facility within a 45 mile radius equipped for their medical needs with exceptions. Trips to out-of-state facilities require prior approval.

(iii) Duals may be transported to any facility within a 45 mile radius equipped for their medical needs with exceptions. Trips to out-of-state facilities require prior approval.

(2) The service provided must be a SoonerCare covered service provided by a medical provider who is enrolled in the SoonerCare program; and

(3) Services requiring prior authorization must have been authorized (e.g. travel that exceeds the 45 mile radius, out-of-state travel, meals and lodging services).

(b) SoonerRide NET is available on a statewide basis to all eligible members.

(c) SoonerRide NET may also be provided for eligible members to providers other than SoonerCare providers if the transportation is to access medically necessary services covered by SoonerCare.

(d) SoonerRide NET is available if a member is being discharged from a facility to their home.  The facility is responsible for scheduling the transportation.

(e) In documented medically necessary instances, a medical escort may accompany the member.

(1) SoonerRide NET is not required to transport any additional individuals other than the one approved individual providing the escort services.  In the event that additional individuals request transportation, the SoonerRide broker may charge those family members according to the SoonerRide broker's policies which have been approved by the OHCA.
(2) A medical escort is not eligible for direct compensation by the SoonerRide broker or SoonerCare.

317:30-5-327.2.Service availability
[Revoked 06-25-12]
.

317:30-5-327.3.Coverage for residents of nursing facilities
[Issued 06-25-07]
(a) An attendant must accompany members during SoonerRide Non-Emergency Transportation (NET). An attendant must be at least at the level of a nurse's aide, and must have the appropriate training necessary to provide any and all assistance to the member, including physical assistance needed to seat the member in the vehicle. The attendant must have the ability to interface with health care providers as appropriate. An attendant must be of an age of legal majority recognized under State law.
(1) The nursing facility must provide an attendant to accompany members receiving NET services.
(2) The attendant will be responsible for any care needed by the member(s) during transport and any assistance needed by the member(s) to assure the safety of all passengers and the driver of the vehicle. An attendant leaves the vehicle at its destination and remains with the member(s).
(3) When multiple members residing in the same nursing facility are being transported to the same provider for health care services, the nursing facility may provide one qualified attendant for each three members unless other circumstances indicate the need for additional attendants. Such circumstances might include but are not limited to:
(A) the physical and/or mental status of the member(s),
(B) difficulty in getting the member(s) in and out of the vehicle,
(C) the amount of time that a member(s) would have to wait unattended, etc.
(4) SoonerRide is not responsible for arranging for an attendant. The services of the attendant are not directly reimbursable by the SoonerRide program or SoonerCare. The cost for the attendant is included in the SoonerCare nursing facility per diem rate.
(5) In certain instances, a family member or legal guardian may wish to accompany the member for health care services. In such instances, the family member or legal guardian may accompany the member in place of the attendant. Only one escort may accompany a member. The escort must be able to provide any services and assistance necessary to assure the safety of the member in the vehicle.
(A) When an escort wishes to accompany the member in place of an attendant provided by the nursing facility, the escort and the nursing facility must sign a release form stating that an escort will be traveling with the member and performing the services which would normally be performed by the attendant. This release must be faxed to the SoonerRide broker's business office prior to the date of the transport.
(B) If an escort is used in place of an attendant provided by the nursing facility, that escort cannot be counted as an escort for any other member who is traveling in the same vehicle.
(C) SoonerRide is not required to transport any additional family members other than the one family member providing escort services. In the event that additional family members request transportation, the SoonerRide broker may charge those family members according to the SoonerRide broker's policies approved by the OHCA.
(D) An escort is not eligible for direct compensation by the SoonerRide broker or SoonerCare.
(b) For members who require non-emergency transportation for dialysis, one attendant is required to accompany a group of up to three dialysis patients when they are being transported for dialysis services. The attendant must remain with the patient(s) unless the provider of the dialysis treatment and the nursing facility sign a release form stating that the presence of the attendant is not necessary during the dialysis treatment. The release must be faxed to the SoonerRide broker's business office prior to the date of the dialysis service.
(1) In instances when an attendant does not remain with the member(s) during dialysis treatment, SoonerRide is not responsible for transporting the attendant back to the nursing facility.
(2) In instances when an attendant does not remain with the member(s) during dialysis treatment, the nursing facility is responsible for providing an attendant to accompany the member(s) on the return trip from the dialysis center. The nursing facility is also responsible for transporting that attendant to the dialysis center in order to accompany the member(s) on the return trip.
(c) In the event that a member is voluntarily moving from one nursing facility to another, SoonerRide will provide NET to the new facility. The nursing facility that the member is moving from will be responsible for scheduling the transportation and providing an attendant for the member.
(d) In the event that a nursing facility's license is terminated, SoonerRide will provide NET to a new nursing facility. The nursing facility that the member is moving from will be responsible for scheduling the NET through SoonerRide and providing an attendant to accompany the member.

317:30-5-327.4.Coverage for children
[Issued 06-25-07]
(a) Services, deemed medically necessary and allowable under federal Medicaid regulations, may be covered by the EPSDT/OHCA Child Health program even though the services may not be part of the OHCA SoonerCare program. Such services must be prior authorized.
(b) Federal Medicaid regulations also require the State to make the determination as to whether the service is medically necessary and do not require the provision of any items or services that the State determines are not safe and effective or which are considered experimental.

317:30-5-327.5.Exclusions from SoonerRide NET

[Revised 01-18-08]
SoonerRide NET excludes:
(1) transportation of members to access emergency services;
(2) transportation of members by ambulance for any reason;
(3) transportation of members to services that are not covered by SoonerCare; and
(4) transportation of members to services that are not medically necessary.

317:30-5-327.6.Denial of SoonerRide NET services by the SoonerRide broker
[Issued 06-25-07]
(a) In addition to the exclusions listed in 317:30-5-327.5 of this Part, the SoonerRide broker may deny NET services if:
(1) the nursing facility/member refuses to cooperate in determining the member's eligibility;
(2) the nursing facility/member refuses to provide the documentation required to determine the medical necessity for NET services;
(3) the member or attendant exhibits uncooperative behavior or misuses/abuses NET services;
(4) the member is not ready to board NET transport at the scheduled time or within 10 minutes after the scheduled pick up time; and
(5) the nursing facility/member fails to request a reservation at least three days in advance of a health care appointment without good cause. Good cause is created by factors such as, but not limit to any of the following:
(A) urgent care;
(B) post-surgical and/or medical follow up care specified by a health care provider to occur in fewer than three days;
(C) imminent availability of an appointment with a specialist when the next available appointment would require a delay of two weeks or more; and
(D) the result of administrative or technical delay caused by SoonerRide and requiring that an appointment be rescheduled.
(b) Pursuant to Federal law, SoonerRide will provide notification in writing to nursing facilities/member when members have been denied services. This notification must include the specific reason for the denial and the member's right to appeal.

317:30-5-327.7.SoonerRide provider network
[Issued 06-25-07]
(a) The SoonerRide broker will maintain an adequate number of appropriate network providers to provide non-emergency, non-ambulance transportation services for eligible members.
(b) If a nursing facility has the capability to provide non-emergency, non-ambulance transportation, the SoonerRide broker may contract with the nursing facility as a NET network provider. The nursing facility must meet the same standards as any other SoonerRide contracted provider for vehicle and driver licensing, safety, training, liability, and ADA regulations. Additionally, when a nursing facility is contracted as a NET provider, the nursing facility cannot limit transportation services to members of a specific nursing facility, but must have the same availability as any other contracted network provider except for the transportation of members for dialysis services.
(c) SoonerRide may contract with other transportation providers solely for the non-emergency, non-ambulance transportation of members for dialysis services.

317:30-5-327.8.Type of services provided and duties of the SoonerRide driver
[Issued 06-25-07]
(a) The SoonerRide NET program is limited to curb-to-curb services. Curb-to-curb services are defined as services for which the vehicle picks up and discharges the passengers at the curb or driveway in front of their place of residence or destination. The SoonerRide NET driver does not provide assistance to passengers along walkways or steps to the door or the residence or other destination. The SoonerRide NET driver will open and close the vehicle doors, load or provide assistance with loading adaptive equipment. Additionally, the SoonerRide NET driver may fasten and unfasten safety restraints when that service is requested by the rider or on behalf of the rider.
(b) If the member is traveling by lift van, the SoonerRide NET driver will load and unload the member according to established protocols for such procedures approved by the Oklahoma Health Care Authority.
(c) The SoonerRide NET driver will deliver the member to the scheduled destination, and is not required to remain with the member.

317:30-5-327.9.Scheduling NET services through SoonerRide
[Issued 06-25-07]
(a) The nursing facility/member will schedule SoonerRide NET services for transportation to covered services. SoonerRide NET services may be scheduled by calling the toll free SoonerRide number or by faxing a request to SoonerRide.
(b) All SoonerRide NET routine services must be scheduled by advance appointment. Appointments must be made at least three business days in advance of the health care appointment, but may be scheduled up to fourteen business days in advance. Scheduling for members with standing appointments may be scheduled for those appointments beyond the 14 days.
(c) NET services for eligible members will be scheduled and obtained through the SoonerRide NET program. The nursing facilities/member will be financially responsible for NET services which are not scheduled for eligible members through the SoonerRide program. The nursing facility may not charge the member or member's family for NET services which were not paid for by SoonerRide because they were not scheduled through SoonerRide in the appropriate manner.
(d) Whenever possible SoonerRide will give consideration for members who request NET for routine care and the request is made less than three business days in advance of the appointment. However, such requests for service are not guaranteed and will depend on the available space and resources.
(e) If SoonerRide cannot provide NET for urgent care, the nursing facility/member may provide the NET transportation and submit proper documentation to SoonerRide for reimbursement. In such cases the nursing facility/member must attempt to schedule the service through SoonerRide first, and obtain a reference number or the service must have become necessary during a time that SoonerRide scheduling was unavailable, such as after hours or weekends. For NET for urgent services provided after hours or on weekends, the nursing facility/member must notify SoonerRide within two business days of the date of service.

317:30-5-328.Subsistence (sleeping accommodations and meals) [REVOKED]

[Revoked 07-01-13]

Disclaimer. The OHCA rules found on this Web site are unofficial. The official rules are published by the Oklahoma Secretary of State Office of Administrative Rules as Title 317 of the Oklahoma Administrative Code. To order an official copy of these rules, contact the Office of Administrative Rules at (405) 521-4911.