Section He-W 572.06 - Mobility Determination Requirements for Scheduled and Routine Ambulance Transportation(a) Medical necessity of a scheduled and routine ambulance transportation shall be documented using the "Mobility Determination for Non-Emergency Medical Transportation Universal Form for All Medicaid Plans" (June 2024), to be a covered service.(b) A "Mobility Determination for Non-Emergency Medical Transportation Universal Form for All Medicaid Plans" (June 2024) shall be completed, signed, and submitted by a healthcare professional such as a registered nurse, medical doctor, care manager, or case manager to the department or its designee by either fax or mail.(c) Mobility determination requests shall be submitted prior to any claim for the service.(d) The department or its designee shall utilize the "Mobility Determination for Non-Emergency Medical Transportation Universal Form for All Medicaid Plans" to determine the most appropriate vehicle type to meet the recipient's medical needs and notify the recipient and the health care provider who submitted the form of the determination, including information that the recipient may appeal the department or designee's decision as to the most appropriate vehicle type for transportation according to medical necessity, in accordance with He-C 200.N.H. Admin. Code § He-W 572.06
(See Revision Note at chapter heading He-W 500); ss by #6641, eff 11-27-97; EXPIRED: 11-27-05
New. #8502, INTERIM, eff 12-2-05, EXPIRES: 5-31-06; ss by #8638, eff 5-30-06; ss by #10294, eff 12-1-13
Amended by Number 2, Filed January 11, 2024, Proposed by #13840, Effective 12/29/2023, Expires 6/26/2024.Amended by Number 28, Filed July 11, 2024, Proposed by #14007, Effective 6/25/2024, Expires 6/25/2034.