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Part 33      TRANSPORTATION BY AMBULANCE

317:30-5-335.Eligible providers
[Revised 12-21-06]
To be eligible for reimbursement, all ambulance service suppliers that operate air, water or ground services (including stretcher service) must be licensed by the State Department of Health (OSDH) consistent with the level of care they provide, in accordance with the Oklahoma Emergency Response System Development Act of 2005, 63 OS 1-2503. Ambulance suppliers that do not provide services in Oklahoma must be licensed by the appropriate agency in the state in which they provide services. Ambulance companies and all other transportation providers must have a current contract on file with the Oklahoma Health Care Authority (OHCA). Air Ambulance providers must indicate on the application for enrollment that they are requesting fixed wing or rotary wing ambulance status and provide a copy of their license with their enrollment application.

317:30-5-335.1.Definitions

[Revised 07-01-13]

The following words and terms, when used in this subchapter shall have the following meaning, unless the context clearly indicates otherwise.

"Ambulance" means a motor vehicle, watercraft, or aircraft that is primarily used or designated as available to provide transportation and basic life support or advanced life support.

"Bed confined" means that the member is unable to get up from bed without assistance, unable to ambulate, and unable to sit in a chair or wheelchair.  The term bed confined is not synonymous with bed rest or non-ambulatory.

"Continuous or round trip" means an ambulance service in which the member is transported to the hospital, the physician deems it medically necessary for the ambulance to wait, and the member is then transported to a more appropriate facility for care or back to the place of origin.

"Emergency/ Emergent" 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 member's health in serious jeopardy, serious impairment to bodily function, or serious dysfunction of any bodily organ or part.

"Emergency transfer" means the movement of an acutely ill or injured member from the scene to a health care facility (pre-hospital), or the movement of an acutely ill or injured member from one health care facility to another health care facility (inter-facility).

"Loaded mileage" means the number of miles for which the member is transported in the ambulance.

"Locality" means the service area surrounding the facility from which individuals normally travel or are expected to travel to seek medical care.

"Medically necessary transport" means an ambulance transport that is required because no other effective and less costly mode of transportation can be used due to the member's medical condition.  The transport is required to transfer the member to and/or from a medically necessary service not available at the primary location.

"Nearest appropriate facility" means that the receiving institution is generally equipped to provide the needed hospital or skilled nursing care for the illness or injury involved.  In the case of a hospital, 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, ambulance service to a more distant hospital solely to avail a member of the service of a specific physician or physician specialist does not make the hospital in which the physician has staff privileges the nearest hospital with appropriate facilities.

"Non-emergency transfer" means the movement of any member in an ambulance other than an emergency transfer.

"Stretcher service" means a non-emergency transport by a ground vehicle that is approved by the OSDH which is designed and equipped to transport individuals on a stretcher or gurney type apparatus that is operated to accommodate an incapacitated or disabled person who does not require medical monitoring, aid, care or treatment during transport.

317:30-5-336.General coverage
[Revised 12-21-06]
OHCA covers ground and air ambulance transportation services, within certain limitations.
(1) Ambulance and stretcher transportation is covered only when medically necessary and when due to the member's condition any other method of transportation is contraindicated.
(2) As a general rule ambulance transportation to the nearest appropriate facility in the locality is covered. OHCA utilizes the locality areas as defined by Medicare.
(b) OHCA recognizes different levels of ambulance medical services by qualified ambulance staff according to the standards established by law and regulation through the Oklahoma Emergency Response System Development Act of 2005, ?63 OS 1-2503.
(c) Ambulance medical services are divided into different levels for payment purposes. Payment is made according to the medically necessary services actually furnished. That is, payment is based on the level of service furnished, not simply on the vehicle used.
(d) Ambulance providers must maintain documentation of the medical necessity and appropriateness of service in the member's file.
(e) Clinical decisions can be made without delay if documentation to support coverage and medical necessity is submitted as part of the initial claim form. This may be accomplished by submitting supporting detailed documentation regarding the member's condition and need for ambulance/stretcher transport.

317:30-5-336.1.Medical necessity
[Issued 12-21-06]
(a) The member's condition must require the ambulance/stretcher transportation itself and the level of service provided, in order for the billed service to be considered medically necessary. Medical necessity is established when the member's condition is such that the use of any other method of transportation is contraindicated.
(b) The medical personnel in attendance, including the Emergency Medical Technician (EMT) at the scene of an emergency, determine medical necessity and appropriateness of service within the scope of accepted medical practice and SoonerCare guidelines.
(c) Non-emergency transports are not covered unless the member is bed confined or has a medical condition that requires medical expertise not available with a less specialized method of transportation. Medical necessity for non-emergency transports must be substantiated with a physician's written order.

317:30-5-336.2.Nearest appropriate facility
[Issued 12-21-06]
(a) OHCA covers transportation to the nearest facility that can appropriately treat the member.
(b) An institution is not considered an appropriate facility if the member's condition requires a higher level of care or specialized services available at the more distant hospital. 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.
(c) An institution is not considered an appropriate facility if no bed is available. However, the medical records must be properly documented.

317:30-5-336.3.Destination
[Issued 12-21-06]
(a) Transportation is covered from the point of origin to the Hospital, Critical Access Hospital or Nursing Facility that is capable of providing the required level and type of care for the member.
(b) Ambulance transportation from a hospital with a higher level of care to a hospital with a lower level of care in the locality is covered, provided all other criteria are met and approved by the OHCA.
(c) Non-emergency transportation to the outpatient facilities of a Hospital, free-standing Ambulatory Surgery Center (ASC), Independent Diagnostic Testing Facility (IDTF), Physician's office or other outpatient facility is compensable if the member's condition necessitates ambulance or stretcher transportation and all other conditions are met.
(d) Ambulance Transportation to a Veteran's Administration (VA) Hospital is covered when the trip has not been authorized by the VA.

317:30-5-336.4.Transport outside of locality

[Revised 07-01-13]

(a) If ambulance transportation is provided out of the transport locality, the claim must be documented with the reason for the transport outside of the service area.

(b) If it is determined the member was transported out of locality and the closest facility could have cared for the member, payment will be made only for the distance to the nearest medical institution with the appropriate facilities.

(c) Any transportation which begins or ends outside of the Oklahoma geographic border requires prior authorization. The exception to this rule is if transportation begins or ends within 100 miles of Oklahoma = s geographic border, no prior authorization is required.

317:30-5-336.5.Levels of ambulance service, ambulance fee schedule and base rate

[Revised 07-01-13]

(a) In accordance with the Oklahoma Emergency Response System Development Act of 2005, ' 63 OS 1-2503, a license may be issued for basic life support, intermediate life support, paramedic life support, specialized mobile intensive care units, or stretcher aid vans.

(b) Payment is made at the lower of the provider's usual and customary charge or the OHCA fee schedule for SoonerCare compensable services.

(1) The ambulance provider bills one base rate procedure.  Levels of service base rates are defined at 42 CFR 414.605.

(2) The base rate must reflect the level of service rendered, not the type of vehicle in which the member was transported.

317:30-5-336.6.Mileage
[Issued 12-21-06]
(a) Charges for mileage must be based on loaded mileage only, i.e., from the pickup of a member to his/her arrival at the destination.
(b) Coverage is allowed only to the nearest appropriate facility.

317:30-5-336.7.Waiting time
[Issued 12-21-06]
(a) Waiting time is reimbursable after the first 30 minutes when a physician deems it medically necessary for the ambulance provider to wait at a hospital while the member is being stabilized, with the intent of continuing the member's transport to an appropriate hospital for care or back to the point of origin.
(b) The maximum number of hours allowed for waiting time is four hours.

317:30-5-336.8.Special situations
[Issued 12-21-06]
(a) Continuous or round trip transport.
(1) If a member is transported to a destination and returned to their original point of pickup, coverage includes payment for the primary transport and the return transport.
(2) If the provider is required to remain and attend the member between transports, the provider may claim waiting time.
(b) Nursing facility.
(1) Ambulance or stretcher transportation from nursing home to nursing home (skilled or intermediate care) is covered if the discharging institution is not certified and the admitting nursing home is certified.
(2) Nursing home to nursing home transports are covered if the member requires care not available at the discharging facility, and the member's medical status requires ambulance transport.
(c) Multiple members per transport.
(1) When more than one eligible member is transported at the same time, the only acceptable duplication of charges is half the base rate.
(2) Separate claims must be submitted for each member.
(3) No mileage or waiting time is to be charged for additional members. These services are included in the reimbursement of the first claim.
(d) Multiple transports per member. More than one transport per member on the same date of service is covered when the member received a different level of service on each transport (e.g., Advanced Life Support 1 and Basic Life Support). When more than one transport with the same level of care occurs on the same day medical necessity must be documented.
(e) Multiple arrivals. When multiple units respond to a call for services, only the entity that actually provides services for the member may bill and be paid for the services by the OHCA. The entity that rendered service/care bills for all services furnished.
(f) No transport. If member refuses treatment after immediate aid has been provided the ambulance may bill the base rate for the level of service and waiting time.
(g) Pronouncement of death.
(1) If the member dies before dispatch, no payment is available.
(2) If the member dies after dispatch, but before the member is loaded, payment is allowed for the base rate but no mileage.
(3) If the member dies after pickup, payment is available for the base rate and mileage.
(4) Time of death is the point at which the member is pronounced dead by an individual authorized by the state to make such pronouncements.
(h) Out of state transports.
(1) Out of state, non-emergency transports require prior authorization.
(2) The ambulance provider, home health agency, hospital, nursing facility, physician, case manager or social worker may request this authorization. The ambulance provider must retain the physician's order of medical necessity in the member's file to support the need for ambulance transportation.
(3) When a member is transported by ground ambulance to or from an air ambulance for out-of-state services, the ground and air ambulance providers providing the transports must bill OHCA independently. When the OHCA is unable to contract for the out-of-state ground transport, the ground and air ambulance charges (air service, medical team, ground transportation) may be consolidated and billed when the following conditions apply.
(A) The air ambulance provider furnishing air transportation (hereafter referred to as "the entity") arranges for ground transportation services and has a contract on file with the OHCA to subcontract for ground ambulance;
(B) The contract includes the requirement that the entity certifies that the ground transportation provider meets the minimum state licensure requirements in the state in which the service is provided;
(C) The entity certifies that the payment will be made to the ground provider;
(i) Neonatal transports.
(1) Coverage of neonatal transport includes neonatal base rate, loaded mileage, transfer isolette, and waiting time.
(2) The intensive care transport of critically ill neonate(s) (i.e. newborns to approved, designated neonatal intensive care units) is a covered service.
(3) When a trained hospital medical team from the receiving or transferring hospital accompanies a newborn on the transport ambulance services, the primary care of the newborn is the hospital team's responsibility, reimbursement for the hospital team is made to the hospital as part of the hospital rate.

317:30-5-336.9.Air ambulance
[Issued 12-21-06]
(a) Air Ambulance service, which includes fixed and rotary wing transportation, are covered only when:
(1) The point of pickup is inaccessible by land vehicle; or,
(2) Great distances or other obstacles are involved in getting the member to the nearest hospital with appropriate facilities and timely admission is essential; i.e., in cases where transportation by land ambulance is contraindicated; or
(3) The member's medical condition and other circumstances of the case necessitated the use of this type of transportation. However, where land ambulance service would have sufficed, payment is based on the amount payable for land ambulance, if this is less costly.
(b) Only one base rate is allowed per trip. Base rate includes the lift off, professional intensive care, transport isolate, ventilator setup, respiratory setup, and all other medical services provided during the flight. No additional payment is made to the air service provider for bedside to bedside service.
(c) If the accident scene is inaccessible by air and a land ambulance must pick up the member to transport to a site where the air ambulance can land, the land ambulance trip is covered. Air transportation is covered only to a hospital in this situation.

317:30-5-336.10.Fixed wing air ambulance services
[Revised 06-25-11]
(a) Fixed wing air ambulance transports must be approved by OHCA. This approval is contingent upon medical necessity.
(b) Ambulance transport in a fixed wing aircraft is a covered service if the following requirements are met:
(1) The transport, including ancillary services (e.g. flight nurse), is ordered by a physician.
(2) The written physician order is maintained in the member's file.
(3) Transport by ground vehicle would endanger the member's life due to time and distance from the hospital.
(4) Medically necessary care or services for the member's medical condition cannot be provided by a local facility.
317:30-5-336.11.Rotary wing air ambulance
[Issued 12-21-06]
Rotary wing air ambulance services are covered by the OHCA only under the following circumstances:
(1) Time and distance in a ground ambulance would be a hazard to the life of the member;
(2) The medically necessary care and services for the member's need are not available at the local hospital, and;
(3) The transfer is for medical or surgical procedures, not solely for diagnostic services only.

317:30-5-336.12.Non-emergency ambulance and stretcher service transportation
[Issued 12-21-06]
(a) OHCA covers non-emergency ground, stretcher and air transportation to and from a medically necessary service. To be covered, the member must be either:
(1) bed confined and unable to use another means of transportation, or
(2) the member's condition must warrant ambulance transportation.
(b) OHCA's Non-emergency Transportation (NET) program, known as SoonerRide, is the first choice for non-emergency transportation for scheduled medical services. SoonerRide provides non-emergency transportation in accordance with all applicable criteria set forth in the American's with Disabilities Act (ADA).
(c) Regularly scheduled non-emergency medical services, such as outpatient dialysis, must be scheduled through SoonerRide unless the member's condition requires transport by stretcher or ambulance. All claims for scheduled trips for outpatient services that cannot be provided by SoonerRide must be accompanied by the medical documentation to substantiate the need for the higher level of transportation and will be reviewed prior to payment by OHCA.
(d) Ambulance or stretcher transport for unscheduled emergent medical care is covered if the trip meets all applicable criteria.

317:30-5-336.13.Non-covered services

[Revised 07-01-13]

(a)  Ambulance transportation from residence to residence is not covered except for transfers from nursing home to nursing home when the transferring facility is not certified.

(b) Payment will not be made for ambulance transportation determined not to be medically necessary.

(c) Transportation to a funeral home, mortuary, or morgue is not covered.

317:30-5-337.Coverage for children
[Revised 12-21-06]
(a) Services, deemed medically necessary and allowable under federal Medicaid regulations, may be covered by the EPSDT/OHCA Child Health program even though those 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.

317:30-5-338.Vocational rehabilitation coverage [REVOKED]
[Revoked 6-27-02]

317:30-5-339.Individuals eligible for Part B of Medicare
[Revised 12-21-06]
Payment for ambulance transportation is made using current Medicare methodology.

317:30-5-340.Procedure codes [REVOKED]
[Revoked 6-27-02]

317:30-5-341.Claim form [REVOKED]
[Revoked 6-27-02]

317:30-5-342.Public transportation [REVOKED]
[Revoked 10-3-05]

317:30-5-343.Reimbursement
[Revised 10-3-05]
Payment is made at the lower of the provider's usual and customary charge or the OHCA's fee schedule.

317:30-5-344.Ground Emergency Medical Transportation (GEMT) supplemental payment program

[Issued 09-14-2020]
(a) Definitions. The following words and terms, when used in this Section, shall have the following meaning, unless the context clearly indicates otherwise:

(1) "Advanced life support" means emergency medical care and services which are provided by a licensed ground ambulance services provider in accordance with Oklahoma Administrative Code (OAC) 310:641, to include, but not limited to, advanced airway management, intravenous therapy, administration of drugs and other medicinal preparations, and other invasive medical procedures and specified techniques that are limited to the Intermediate, Advanced EMT, and Paramedic scope of practice in accordance with OAC 310:641, Subchapter 5.

(2) "Allowable costs" means an expenditure that complies with the regulatory principles as listed in Title 2 of the Code of Federal Regulations (C.F.R.), Section 200.

(3) "Basic life support" means emergency medical care and services which are provided by a licensed ground ambulance service in accordance with OAC 310:641 to include, but not limited to, cardiopulmonary resuscitation procedures (CPR), hemorrhage control, stabilization of actual or possible skeletal injuries, spinal immobilization, extrication, transportation, and other non-invasive medical care.

(4) "Contracts with a local government" means contracts pursuant to a county plan for ambulance and emergency medical services with a:

(A) City, county, or an Indian tribe as defined in Section 4 of the Indian Self-Determination and Education Assistance Act; or

(B) Local service district, including, but not limited to, a rural fire protection district, or all administrative subdivisions of such city, county, or local service district.

(5) "Eligible GEMT provider" means a GEMT provider that meets all eligibility requirements in OAC 317:30-5-344 and the Oklahoma Medicaid State Plan (State Plan).

(6) "Federal financial participation (FFP)" means the portion of medical assistance expenditures for emergency medical services that are paid or reimbursed by the Centers for Medicare and Medicaid Services (CMS) in accordance with the State Plan.

(7) "GEMT services" means the act of transporting an individual by ground from any point of origin to the nearest medical facility capable of meeting the emergency medical needs of the patient, as well as the advanced, limited-advanced, and basic life support services provided to an individual by eligible GEMT providers before or during the act of transportation.

(8) "Governmental unit" means the entire state, local, or federally-recognized Indian tribal government, including any component thereof.

(9) "Publically owned or operated" means a unit of government that is a state, a city, a county, a special purpose district, or other governmental unit in a state that has taxing authority, has direct access to tax revenues, or is an Indian tribe as defined in Section 4 of the Indian Self-Determination and Education Assistance Act.

(b) Purpose. In accordance with 63 Oklahoma Statutes (O.S.) ' 3242, the GEMT Supplemental Payment Program is a voluntary program which makes supplemental payments above the Medicaid fee schedule reimbursement rate to eligible GEMT providers for specific allowable, certified, and uncompensated costs incurred for providing GEMT Services to SoonerCare members.

(c) Provider eligibility. To be eligible for supplemental payments, a GEMT provider must meet all of the following requirements:

(1) Be enrolled as an Oklahoma SoonerCare provider for the time period claimed on its annual cost report;

(2) Provide ground ambulance transportation services to SoonerCare members;

(3) Be classified as a governmental unit provider in accordance with 2 C.F.R. 200;

(4) Comply with all applicable state and federal law;

(5) Be an organization that:

(A) Is publicly owned or operated; or

(B) Is under contract with a local government unit.  A copy of any such contract must be submitted to the Oklahoma Health Care Authority (OHCA) simultaneous with the submission of the GEMT provider's annual cost report; and

(6) Timely submit all relevant information requested by the OHCA, in the format as prescribed by the OHCA, including, but not limited to, a certification that conforms with 42 C.F.R. ' 433.51 that certifies that the claimed expenditures for GEMT Services are eligible for FFP.

(d) Allowable costs.

(1) Supplemental payments provided by this program are available only for the specific allowable costs per medical transport of a SoonerCare member that are in excess of the reimbursement paid by Medicaid and all other insurers and/or third-party resources.

(2) Total reimbursement from SoonerCare, including the supplemental payment, when combined with all other sources of reimbursement, must not exceed one-hundred percent (100%) of actual costs of providing services to SoonerCare members.

(e) Payments and recoupment.

(1) The OHCA will make annual supplemental payments after the conclusion of each state fiscal year (SFY) and in accordance with the methodology outlined in the State Plan.  The payments will be made in the form of an interim payment and a later reconciliation payment (i.e., settle-up payment).  The payments are not an increase to current fee-for-service (FFS) reimbursement rates.

(2) The interim supplemental payment will be equal to seventy-five percent (75%) of the total allowable costs as indicated on the annual approved cost report.

(3) The reconciliation payment will be computed by the OHCA based on the difference between the interim supplemental payment and total allowable costs from the approved cost report.

(4) Any excess payments determined in the reconciliation process are recouped and the federal share is returned to CMS.

(5) Cost reconciliation and cost settlement processes will be completed within twelve (12) months of the end of the cost reporting period.

(f) Reporting requirements.

(1) Eligible GEMT providers will:

(A) Submit a CMS-approved cost report annually, no later than ninety (90) days after the close of the SFY, on a form approved by the OHCA, unless a provider has made a written request for an extension and such request is granted by the OHCA;

(i) After the ninety (90) day deadline, an extension of no more than fifteen (15) calendar days can be granted; and

(ii) Extensions of time shall be requested by a letter addressed to the Finance Division.  Any such request must be received by October 1, and must explain the good faith reason for the extension.  OHCA shall provide a written notice of any denial of a request for an extension, which shall become effective on the date it is mailed.

(B) Provide supporting documentation simultaneous with the cost report, as required by the OHCA;

(C) Keep, maintain, and have readily retrievable, such records as specified by the OHCA to fully disclose reimbursement amounts to which the eligible governmental entity is entitled, and any other records required by CMS; and

(D) Comply with the allowable cost requirements provided in 42 C.F.R. Part 413, 2 C.F.R. Part 200, and federal Medicaid non-institutional reimbursement policy.

(2) Penalties for false statements or misrepresentations made by or on behalf of the provider are established by 42 U.S.C. Section 1320a-7b which states, in part, "Whoever Y (2) at any time knowingly and willfully makes or causes to be made any false statement or representation of a material fact for use in determining rights to such benefit or payment Y shall (i) in the case of such a statement, representation, concealment, failure, or conversion by any person in connection with the furnishing (by that person) of items or services for which payment is or may be under the program, be guilty of a felony and upon conviction thereof fined not more than $100,000 or imprisoned for not more than 10 years or both, or (ii) in the case of such a statement, representation, concealment, failure, conversion, or provision of counsel or assistance by any other person, be guilty of a misdemeanor and upon conviction thereof fined not more than $20,000 or imprisoned for not more than one (1) year, or both."

(g) Agency responsibilities.  The OHCA will:

(1) Submit claims to CMS based on total computable certified expenditures for GEMT services provided, that are allowable and in compliance with federal laws and regulations and Medicaid non-institutional reimbursement policy;

(2) Submit on an annual basis, any necessary materials to the federal government to provide assurances that claims will include only those expenditures that are allowable under federal law; and

(3) Complete the audit and final reconciliation process of the interim cost settlement payments for the services provided within twelve (12) months of the postmark date of the cost report and conduct on-site audits as necessary.

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.