N.J. Admin. Code § 10:50-1.6

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

Section 10:50-1.6 - Reimbursement policy for emergency transportation services

(a) The least expensive mode of emergency transportation suitable to the Medicaid/NJ FamilyCare fee-for-service beneficiary's needs shall be used.

(b) Mileage for ground ambulance service shall be measured by odometer from the point at which the Medicaid/NJ FamilyCare fee-for-service beneficiary enters the vehicle to the point at which he or she exits the vehicle.

1. Medicaid/NJ FamilyCare fee-for-service beneficiaries shall be transported in a manner that results in the accrual of the least number of miles.

2. There may be instances in which a driver takes a faster-but-longer route to avoid traffic congestion or road construction. Mileage based on the faster-but-longer route shall be acceptable if the reason for the route is fully documented on the Transportation Certification Form.

(c) For emergency trips by ground ambulance in excess of 15 miles one way, loaded mileage is reimbursable beginning with the first mile, at a higher rate as indicated at N.J.A.C. 10:50-2, Healthcare Common Procedure Coding System (HCPCS). The higher rate of reimbursement is applicable both to the one-way trip and to the return/round trip.

(d) There is no reimbursement for waiting time on round trips, and it is limited to a maximum of one hour on one-way trips at the point of destination, not at the point of departure.

(e) Emergency transportation service provided to a Medicaid/NJ FamilyCare fee-for-service beneficiary is reimbursable by the New Jersey Medicaid/NJ FamilyCare program under the following conditions only:

1. The medical care provider/facility to which and/or from which the beneficiary is being transported either participates as a provider in the Medicaid/NJ FamilyCare program or meets the requirements for participation as a provider in the Medicaid/NJ FamilyCare program; and

2. The medical service rendered to the beneficiary by the provider/facility is a covered Medicaid/NJ FamilyCare service (as listed at N.J.A.C. 10:49) at the time the transportation is provided.

(f) Reimbursement shall not be permitted when a Medicaid/NJ FamilyCare fee-for-service beneficiary is transported under the following conditions:

1. For the purpose of obtaining a non Medicaid/NJ FamilyCare-covered service, such as a service that is primarily educational, vocational, or social in nature;

2. From home to a medical day care center or the reverse;

3 From a medical day care center to any service provided indirectly by a medical day care center; and

4 From a nursing facility to a clinic to obtain partial care services, as indicated in N.J.A.C. 10:63-2.20(a)6.

(g) For ambulatory individuals, if other modes of transportation are appropriate or available, Medicaid/NJ FamilyCare fee-for-service beneficiaries do not qualify for ambulance service. The appropriate Medicaid/NJ FamilyCare-reimbursed modes of transportation service for ambulatory individuals, in most cases, are public transportation, livery, clinic van, taxicab, bus, or county-administered, lower modes of service.

1. An ambulatory Medicaid/NJ FamilyCare fee-for-service beneficiary's need for ambulance service is not established solely by the fact that a driver escorts or accompanies an individual who has no mobility related problem, is not of full legal age (a minor child), or is unable to communicate in the English language.

2. Trips by ambulance provided to ambulatory Medicaid/NJ FamilyCare fee-for-service beneficiaries to or from a clinic that provides Medicaid/NJ FamilyCare reimbursed van service for the clinic's ambulatory clients are not appropriate and shall not be Medicaid/NJ FamilyCare reimbursable.

(h) Air ambulance (rotary wing) reimbursement shall be based on a rate authorized by the Division of Medical Assistance and Health Services, not to exceed the charge made to non-Medicaid/NJ FamilyCare beneficiaries for the same service.

1. Reimbursement for rotary wing air ambulance services provided to a beneficiary enrolled in managed care shall be the responsibility of the MCO in which the beneficiary is enrolled.

(i) Hospital-based transportation service provided to a Medicaid/NJ FamilyCare fee-for-service beneficiary shall be recognized by the Division as a covered outpatient hospital service under the conditions set forth in the hospital services rules, specifically N.J.A.C. 10:52-2.16.

(j) When an independent transportation provider renders a round trip service to a Medicaid/NJ FamilyCare fee-for-service beneficiary in a general hospital whose status remains "inpatient," the independent transportation provider bills the hospital for the service.

(k) If a nursing facility transports a Medicaid/NJ FamilyCare fee-for-service beneficiary, reimbursement is considered as part of the per diem rate. No further reimbursement is allowed.

(l) No additional payment is made for the use of medical supplies and/or equipment. Exception: Oxygen is reimbursable on a per occurrence basis when provided to a Medicaid/NJ FamilyCare fee-for-service beneficiary during an ambulance trip.

(m) If a transportation service is operated by an organization which has established a policy of providing service without cost for a specific class of individuals, or individuals living within a given area, then it shall be understood that such service is also available without cost to individuals falling within such category who are covered under the New Jersey Medicaid/NJ FamilyCare program.

(n) A transportation company shall not charge the New Jersey Medicaid/NJ FamilyCare fee-for-service program a higher rate than the rate charged by the transportation company to provide similar service to private-pay, non-New Jersey Medicaid/NJ FamilyCare-covered individuals.

(o) Mileage shall be reimbursed in full miles only. Distances of .4 miles or less shall be rounded down to the last full mile and distances of .5 miles or greater shall be rounded up to the next full mile for reimbursement purposes.

N.J. Admin. Code § 10:50-1.6

Amended by R.1985 d.427, effective 8/19/1985.
See: 17 New Jersey Register 1373(a), 17 New Jersey Register 2044(a).
Substantially amended.
Amended by R.1985 d.473, effective 9/16/1985.
See: 17 New Jersey Register 1637(a), 17 New Jersey Register 2271(a).
Substantially amended.
Amended by R.1986 d.236, effective 6/16/1986 (operative July 1, 1986).
See: 18 New Jersey Register 803(a), 18 New Jersey Register 1287(a).
Text added to (g) "For recipients in ... refer to N.J.A.C. 10:49-1.2".
Amended by R.1988 d.262, effective 6/6/1988.
See: 20 New Jersey Register 2103(a), 20 New Jersey Register 1214(a).
Recodified from 1.5 and substantially amended.
Amended by R.1990 d.592, effective 12/3/1990.
See: 22 New Jersey Register 1513(a), 22 New Jersey Register 3620(c).
Section title changed to "Reimbursement Policy" from "Basis of Payment." Deleted and revised subsections (a)-(e); added new (h)-(k), recodifying (f)-(i) as (d)-(g), with new text specifying reimbursement policy.
Amended by R.1991 d.167, effective 4/1/1991.
See: 23 New Jersey Register 5(a), 23 New Jersey Register 1006(a).
Added new subsection (c), recodifying prior (c) as new (d), with no change in text. Deleted existing (d) and recodified (d)1 as new subsection (e); deleted (d)2 and recodified existing (e) as new (f). Recodified existing (f)-(k) as (g)-(l), with no change in text. Changes were made to clarify reimbursement policy regarding Medically Needy, rebundling and non-covered Medicaid services.
Amended by R.1992 d.83, effective 2/18/1992.
See: 23 New Jersey Register 3619(a), 24 New Jersey Register 610(a).
Stylistic revisions throughout. In (a)2: added text regarding the "least expensive mode of transportation."
Amended by R.1992 d.447, effective 11/16/1992.
See: 24 New Jersey Register 2517(a), 24 New Jersey Register 4264(a).
Replaced subsection (a) with new text at subsections (a)-(f); recodified definitions in subsection (a) to definitions at N.J.A.C. 10:50-1.2.
Recodified existing (b)-(h) as (g)-(m). Deleted existing subsection (i) and recodified (j)-(l) as (n)-(p).
Amended by R.1994 d.402, effective 8/1/1994 (operative August 15, 1994).
See: 26 New Jersey Register 1425(a), 26 New Jersey Register 3211(b).
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; inserted references NJ KidCare fee-for-service throughout; in (f), (m) and (n), inserted references to the NJ KidCare program; in (g)1, inserted a reference to non-NJ KidCare-covered service; and in (n), inserted a reference to the NJ KidCare-Plan A program.
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).
In (g), added 4; in (h), inserted references to ambulance or ambulance service preceding "mobility assistance" throughout; rewrote (i); substituted "FamilyCare" for "KidCare" throughout.
Amended by R.2006 d.213, effective 6/19/2006.
See: 37 N.J.R. 4850(a), 38 N.J.R. 2713(a).
In (d), substituted "Healthcare" for "HCFA" and "both to" for "to both"; in (i), substituted "wing or rotary wing" for "wings"; substituted "2.16" for "2.15" in (j); and added (q).

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