N.J. Admin. Code § 10:50-1.5

Current through Register Vol. 56, No. 12, June 17, 2024

Section 10:50-1.5 - Authorization for air ambulance services

(a) Authorization from the Division of Medical Assistance and Health Services' contracted transportation broker is required for all fixed wing air ambulance services.

1. The use of a rotary wing air ambulance is retroactively authorized and includes the approval for fee-for-service reimbursement of a set rate plus mileage costs per loaded mile.

2. For Medicaid/NJ FamilyCare beneficiaries enrolled in a managed care organization (MCO), the reimbursement of the rotary wing air ambulance, as well as its associated loaded mileage, shall be the responsibility of the MCO.

(b) Procedures for obtaining authorization for the use of a rotary wing air ambulance shall be as follows:

1. The provider shall submit a Transportation Prior Authorization Form (MC-12(A)) to the Transportation Coordinator, DMAHS, PO Box 712, Trenton, NJ 08625-0712. Upon receipt of this document, a staff person reviews the information to verify the medical necessity for the use of the respective mode of transportation and approves or denies the request. The data is then sent electronically to the Fiscal Agent. If the request is approved, the provider is notified in writing by the Fiscal Agent of the decision and the authorized date or time frame. If the request is denied or if additional information is required, the provider is notified in writing by the Fiscal Agent.

(c) Retroactive authorization for rotary wing air ambulance services rendered to a Medicaid/NJ FamilyCare fee-for-service beneficiary includes approval of both the service and the rate of reimbursement for the service as indicated at N.J.A.C. 10:50-1.6(h).

1. The following documentation shall be submitted to the Transportation Coordinator at the address at (b)1 above in support of both written and oral requests for air ambulance authorization:

i. A detailed explanation of the reason(s) why air ambulance service, as opposed to ground ambulance service or mobility assistance vehicle service, is medically considered the only acceptable form of travel, as indicated at N.J.A.C. 10:50-1.6(d);

ii. A detailed description of the beneficiary's health condition at the time of transport;

iii. A log showing actual flight time; and

iv. An itemized bill.

2. As indicated in 10:50-1.4(a)6, reimbursement for the use of air ambulance service may be considered only under extenuating circumstances after all alternative, less costly modes of transportation have been considered and ruled out.

(d) Retroactive requests for authorization for new services will be evaluated based on the standards in this subsection. Retroactive requests for renewals of existing periods of authorization shall not be approved. When communication between the provider and the MACC or other program-designated agent of the Division of Medical Assistance and Health Services cannot be established and the provision of the service cannot be delayed, the provider may perform the service. In such instances, the provider shall request retroactive authorization within 10 working days from the date of service. The request for retroactive authorization shall follow the procedures specified in (b)1 above. The provider will be notified in writing by the Fiscal Agent that the request has been approved, denied, or that additional information is required. A retroactive request for authorization shall be accompanied by a properly completed, signed, and dated transportation certification form, as required by 10:50-1.7, for each requested date of service for each beneficiary.

(e) A photocopy of the MC-12(A) form shall be retained on file at the provider's place of business for a minimum period of five years from the date the corresponding service was rendered. The MC-12(A) form shall be made available for review upon request by staff of the Division of Medical Assistance and Health Services or the Division's Fiscal Agent during this period of time. If a MC-12(A) form is not on file for each service, or does not contain all the required documentation as indicated in this section, Medicaid/NJ FamilyCare reimbursement for the service is subject to recoupment as indicated at N.J.A.C. 10:49-9.9.

N.J. Admin. Code § 10:50-1.5

New Rule, R.1988 d.262, effective 6/6/1988.
See: 19 New Jersey Register 2103(a), 20 New Jersey Register 1214(a).
Section 1.5 was recodified to 1.6.
Amended by R.1990 d.592, effective 12/3/1990.
See: 22 New Jersey Register 1513(a), 22 New Jersey Register 3620(c).
Added new subsection (f).
In (a): added reference to subsection (f); added "ground" to define ambulance service.
In (b): replaced "professional staff person" for "MDO consultant" and/or "medical consultant."
In (d): stylistic revisions and updates, deleting reference to "Prudential" fiscal agent.
Administrative Correction to (d).
See: 23 New Jersey Register 63(a).
Amended by R.1992 d.83, effective 2/18/1992.
See: 23 New Jersey Register 3619(a), 24 New Jersey Register 610(a).
In (a)-(d): text revised to clarify prior authorization and reimbursement procedures for providers under new Fiscal Agent.
In (e)-(f): stylistic revisions.
Amended by R.1999 d.5, effective 1/4/1999.
See: 30 New Jersey Register 3625(a), 31 New Jersey Register 58(a).
Substituted references to beneficiaries for references to recipients throughout; substituted "mobility assistance vehicle" for "invalid coach" throughout; in (a), inserted a reference to NJ KidCare fee-for-service; and in (d) and (f), inserted references to NJ KidCare.
Amended by R.1999 d.370, effective 11/1/1999.
See: 31 New Jersey Register 847(a), 31 New Jersey Register 3325(a).
In (c), changed N.J.A.C. reference in the introductory paragraph; and added (g) and (h).
Amended by R.2000 d.501, effective 1/16/2001.
See: 32 New Jersey Register 2397(a), 33 New Jersey Register 322(a).
Rewrote the section.
Amended by R.2002 d.170, effective 6/3/2002.
See: 34 New Jersey Register 635(a), 34 New Jersey Register 1925(a).
Rewrote the section.
Amended by R.2006 d.213, effective 6/19/2006.
See: 37 N.J.R. 4850(a), 38 N.J.R. 2713(a).
Inserted "and shall be obtained" in (a); substituted "shall be" for "are" in (b); in (c), substituted "wing or rotary wing" for "wings"; in the introductory paragraph of (g), deleted "or intermediate care facility for the mentally retarded", substituted "8:85" for "10:63" and added last sentence; deleted (g)1; and divided (h) into three sentences by inserting a period and capitalizing "A".

Amended by 54 N.J.R. 620(b), effective 4/4/2022