Ariz. Admin. Code § 9-22-211

Current through Register Vol. 30, No. 50, December 13, 2024

Section R9-22-211 - Transportation Services

A. Emergency ambulance services.

1. A member shall receive medically necessary emergency transportation in a ground or air ambulance:

a. To the nearest appropriate provider or medical facility capable of meeting the member's medical needs, and

b. If no other appropriate means of transportation is available.

2. The Administration or a member's contractor shall reimburse a ground or air ambulance transport that originates in response to a 911 call or other emergency response system:

a. If the member's medical condition justifies the medical necessity of the type of ambulance transportation received,

b. The transport is to the nearest appropriate provider or medical facility capable of meeting the member's medical needs, and

c. No prior authorization is required for reimbursement of these transports.

3. The member's medical condition at the time of transport determines whether the transport is medically necessary.

4. A ground or air ambulance provider furnishing transport in response to a 911 call or other emergency response system shall notify the member's contractor within 10 working days from the date of transport. Failure of the provider to provide notification is cause for denial.

5. Notification to the Administration of emergency transportation provided to a FFS member is not required, but the provider shall submit documentation with the claim that justifies the service.

B. The Administration or a contractor covers air ambulance services only if at least one criterion in subsection (B)(1) is met and at least one criterion in subsection (B)(2), or the criterion in subsection (B)(3) is met. The criteria are:

1. The air ambulance transport is initiated at the request of:

a. An emergency response unit,

b. A law enforcement official,

c. A clinic or hospital medical staff member, or

d. A physician or practitioner, and

2. The point of pickup:

a. Is inaccessible by ground ambulance, or

b. Is a great distance from the nearest hospital or other provider with appropriate facilities to treat the member's condition and ground ambulance service will not suffice, or

3. The medical condition of the member requires immediate intervention from emergency ambulance personnel or providers with the appropriate facilities to treat the member's condition.

C. Coverage of medically necessary nonemergency transportation is limited to the cost of transporting the member to an appropriate provider capable of meeting the member's medical needs.

1. As specified in contract, a contractor shall arrange or provide medically necessary nonemergency transportation services for a member who is unable to arrange transportation to a service site or location.

2. For a fee-for-service member, the Administration shall authorize medically necessary nonemergency transportation for a member who is unable to arrange transportation to a service site or location.

D. For the purposes of this subsection, an individual means a person who is not in the business of providing transportation services such as a family or household member, friend, or neighbor. The Administration or a contractor shall cover expenses for transportation in traveling to and returning from an approved and prior authorized health care service site provided by an individual if:

1. The transportation services are authorized by the Administration or the member's contractor or designee,

2. The individual is an AHCCCS registered provider, and

3. No other means of appropriate transportation is available.

E. The Administration or a contractor shall cover expenses for meals, lodging, and transportation for a member traveling to and returning from an approved health care service site outside of the member's service area or county of residence.

F. The Administration or a contractor shall cover the expense of meals, lodging, and transportation for:

1. A family member accompanying a member if:

a. The member is traveling to or returning from an approved health care service site outside of the member's service area or county of residence; and

b. The meals, lodging, and transportation services are authorized by the Administration or the member's contractor or designee.

2. An escort who is not a family member as follows:

a. If the member is travelling to or returning from an approved and prior authorized health care service site, including an inpatient facility, outside of the member's service area or county of residence;

b. If the escort services are authorized by the Administration or the member's contractor or designee; and

c. Wage paid to an escort as reimbursement shall not exceed the federal minimum wage.

G. A provider shall obtain prior authorization from the Administration for transportation services provided for a member for the following:

1. Medically necessary nonemergency transportation services not originated through a 911 call or other emergency response system when the distance traveled exceeds 100 miles (whether one way or round trip); and

2. All meals, lodging, and services of an escort accompanying the member under this Section.

H. A charitable organization routinely providing transportation service at no cost to an ambulatory or chairbound person shall not charge or seek reimbursement from the Administration or a contractor for the provision of the service to a member but may enter into a subcontract with a contractor for medically necessary transportation services provided to a member.

Ariz. Admin. Code § R9-22-211

Adopted as an emergency effective May 20, 1982 pursuant to A.R.S. § 41-1003, valid for only 90 days (Supp. 82-3). Former Section R9-22-211 adopted as an emergency now adopted and amended as a permanent rule effective August 30, 1982 (Supp. 82-4). Amended effective October 1, 1985 (Supp. 85-5). Amended subsection (A) effective October 1, 1986 (Supp. 86-5). Amended effective December 13, 1993 (Supp. 93-4). Amended effective September 22, 1997 (Supp. 97-3). Amended by final rulemaking at 8 A.A.R. 2325, effective May 9, 2002 (Supp. 02-2). Amended by final rulemaking at 17 A.A.R. 1658, effective August 2, 2011 (Supp. 11-3).