Section 405IAC5-30-1. Reimbursement restrictions

   Medicaid reimbursement is available for emergency and nonemergency transportation, subject to the following restrictions:

(1) Except when additional trips are medically necessary and the same is demonstrated and documented through the prior authorization process, reimbursement is available for a maximum of twenty (20) one-way trips per member, per rolling twelve (12) month period of time. The following services are exempt from the numeric cap and do not require prior authorization, except as specified in subdivision (2):

(A) Emergency ambulance services.

(B) Transportation to or from a hospital for the purpose of an inpatient admission or discharge. This includes interhospital transfers when the member has been discharged from one (1) hospital for the purpose of admission to another hospital.

(C) Transportation for members on renal dialysis or those residing in nursing homes.

(D) Accompanying parent or member attendant, or both.

(E) Return trip from the emergency room in an ambulance, if use of ambulance is medically necessary for the transport.

(2) Prior authorization is required for all trips of fifty (50) miles or more one (1) way.

(3) Service must be for transportation to or from an Indiana Medicaid covered service, or both. The member being transported for treatment must be present in the vehicle in order for Medicaid reimbursement to be available. Providers must comply with all applicable Medicaid documentation requirements, as set forth in provider manuals or bulletins, in effect on the date of service.

(4) Transportation must be unavailable from a non-Medicaid reimbursed source, with the exception of Medicaid payments for family member mileage. This source may include, but is not limited to, the following:

(A) A member owned vehicle.

(B) A volunteer organization.

(C) Willing family or friends.

(5) Transportation must be the least expensive type of transportation available that meets the medical needs of the member.

(6) The office must authorize all in-state train, bus, or family member transportation services. The member or a party acting on the member's behalf must make the request for any required authorization to the office. For purposes of this rule, in-state includes out-of-state designated areas.

(7) When a member needs airline, air ambulance, interstate transportation, or transportation services from a provider located out-of-state in a nondesignated area, the office or the physician must forward the request for authorization by telephone or in writing to the contractor. Telephone requests must be followed up in writing. The request must include a description of the anticipated care and a brief description of the clinical circumstances necessitating the need for transportation by air or to another state, or both. The contractor will review the request. If authorized, the transportation provider will receive the authorization to arrange the transportation. Copies of the prior authorization decision are sent to the member and the rendering provider.

(8) A provider is not entitled to Medicaid reimbursement in any amount that exceeds what the provider accepts as payment in full (including any coupon, cash discount, or other type of discount) for the same or equivalent services provided to any non-Medicaid customer.

(Office of the Secretary of Family and Social Services; 405 IAC 5-30-1; filed Jul 25, 1997, 4:00 p.m.: 20 IR 3357; filed Sep 27, 1999, 8:55 a.m.: 23 IR 321; readopted filed Jun 27, 2001, 9:40 a.m.: 24 IR 3822; readopted filed Sep 19, 2007, 12:16 p.m.: 20071010-IR-405070311RFA; readopted filed Oct 28, 2013, 3:18 p.m.: 20131127-IR-405130241RFA; filed Aug 1, 2016, 3:44 p.m.: 20160831-IR-405150418FRA; errata filed Nov 1, 2016, 9:36 a.m.: 20161109-IR-405160493ACA)