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Provider Notice issued 11/22/13

Prior Approval for Non-Emergency Ambulance Services

To:​ Enrolled Ambulance and Hospital Providers​
Date:​ November 22, 2013​
Re:​ Prior Approval for Non-Emergency Ambulance Services​

The purpose of this notice is to remind providers of a new law affecting hospitals when discharging Medicaid patients by ambulance. During the implementation phase, the department has experienced issues indicating that hospitals may need clarification with regard to the policy, which was announced in the July 1, 2013 Informational Notice, Prior Approval for Non-Emergency Ambulance Services (pdf).

In accordance with Public Act 97-0689, and 89 IL Admin Code 140.491(c), when a patient is discharged from a hospital, the treating provider (or their designee) must complete a medical certification justifying the medical necessity of the ambulance-level transport. Within that certification, the provider is attesting that a lower level of transportation service (service car/medicar/wheelchair van/taxi/private automobile) is contraindicated. The criteria for non-emergency ambulance transportation can be found at 89 IL Admin code 140.TABLE A. This certification is completed using the department's Medical Certification for Ambulance Services (MCA) form found by selecting MCA Form on the Non-Emergency Transportation Services Prior Approval Program (NETSPAP) website.

In accordance with 89 IL Admin Code 140.491(c)(4), facilities, including hospitals, must develop procedures to ensure the completion of the MCA Form prior to the patient's discharge from the facility and prior to the non-emergency ambulance service being provided.  

Not all hospitals are completing the required MCA Form prior to discharge, and some are not transmitting the form to the department and the ambulance provider prior to transport. The form must be completed prior to discharge, and must be submitted to the department's prior approval contractor, currently First Transit, as well as the transportation provider prior to the transportation service being provided. The hospital must also provide a copy of the MCA form to the ambulance crew upon patient pickup. Hospitals are reminded to ensure that all staff responsible for discharges, including both inpatient discharges and emergency room discharges, are aware of the hospital's procedures for compliance with this requirement.

In many cases, MCA forms are either incomplete or illegible. Hospitals are encouraged to use the online, e-mail able, encrypted version of the MCA Form available at NETSPAP.com, which will alleviate the problem in most instances. This option provides on-screen help via hover comments that prompt users when a required field was not completed on the form. The current version has been finalized and no revisions are planned.

When the hospital provider submits the MCA Form to First Transit, a prior approval is granted based on the provider's attestation that the requested ambulance service at the requested level of service is medically necessary. Ambulance-level services are not a covered service when a less expensive mode of transportation would have met the patient's needs.

Pursuant to Subsection E of Section 12-4.25 of the Illinois Public Aid Code, the department is entitled to recover overpayments paid to a provider or vendor, including, but not limited to, from the discharging physician and the discharging facility in instances where a non-emergency ground ambulance service is rendered as the result of improper or false certification. It is imperative that hospitals comply with all MCA requirements.

Effective immediately, when the department becomes aware that a hospital is not complying with the MCA requirements, the department's NETSPAP contractor, First Transit, will contact the hospital to provide education. The department will follow with a letter to the hospital documenting the contact and discussion. If the hospital remains non-compliant, the department's Office of Inspector General may request that the hospital provide a corrective action plan as well as documentation of the procedures that the hospital developed in accordance with 89 IL Admin Code 140.491(c)(4),

The department is committed to assisting both hospital and transportation providers in understanding and complying with the requirement. The department holds weekly conference calls on Thursdays at 9:30, and will continue to do so throughout implementation. The conference call number is 888-494-4032, passcode 7212487979#. In addition, a separate e-mail address has been established which is dedicated to questions relating to this requirement. The e-mail address is hfs.mcaform@illinois.gov. Questions regarding this notice may be directed to First Transit at 1-877-725-0569.

Theresa A. Eagleson, Administrator

Division of Medical Programs

 

Illinois Healthcare and Family Services

JB Pritzker, Governor • Theresa Eagleson, Director