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  • Medical Transportation Procedures > General Information and Contacts

    This chapter contains our plan policies related to medically necessary transportation services for Medicaid members to and from health care appointments (including Child/Teen Health Program [C/THP] appointments for all children under age 21), whether services are covered by EmblemHealth or by Medicaid fee-for-service (FFS). It also includes plan policies related to medically necessary transportation services for members enrolled in our Medicaid Advantage and Managed Long Term Care (MLTC) benefit plans. In counties where transportation services are covered by Medicaid FFS, information on how to access services through the local department of social services or other Medicaid FFS transportation vendor is provided.

    Emergency Transportation
    Transportation in the event of a medical emergency does not require a prior approval for any of our members, including ASO and Commercial/CHPlus, as well as members in Medicare plans which are not otherwise covered in this chapter. All members are instructed to dial 911 to obtain immediate assistance.

    Dual Eligible HMO SNP
    These members, while "dual eligible" may only have very limited Medicaid coverage, e.g., Medicaid only covers payment of members' Medicare Part B, and may therefore not have transportation coverage through Medicaid FFS. Where members have both Medicare and Medicaid coverage for the same transportation service, the Medicare coverage is primary and considered part of their benefits through our plan.

    Distance Travel Standards

    Members are expected to select primary care physicians (PCPs) whose offices are within a reasonable proximity to their residence. Members are not entitled to transportation for distances less than 10 blocks unless there are special circumstances such as a physical disability.

    Public Transportation

    In New York City, members must use public transportation unless a specific medical condition contraindicates such use.

    General Reimbursement When the Plan Covers Transportation

    1. Health care providers (e.g., PCPs, OB/GYNs, physician group practices and dentists) are to reimburse members for round-trip public transportation to medical appointments and to appointments to which they refer members, including specialist appointments.
    2. EmblemHealth, or the applicable Managing Entity financially responsible for transportation services, will:
      • Reimburse health care providers who dispense car fare to members upon submission of a properly completed Public Mass Transportation Reimbursement Ledger. Separate ledgers must be used to record transportation disbursements to members for whom a Managing Entity is financially responsible, and ledgers must be submitted to the Managing Entity.
      • Reimburse health care providers who submit FFS claims when they include the transportation expense on the claims for the visit using CPT codes (Livery/Taxi A0100, Ambulette A0130 and Ambulance A0425 Mileage, A0426 ALS Non ER, A0427 ALS ER, A0428 BLS Non ER and A0429 BLS ER).
      • Reimburse transportation costs for escorts of children and escorts for members of any age when medically necessary.
      • Reimburse contracted taxi, ambulette and ambulance providers directly.

    Exception: The Plan does not reimburse members for use of private vehicles.

    EmblemHealth Contact Information When Transportation Is Covered by the Plan

    1. Members with HIP or HealthCare Partners (HCP) as their assigned Managing Entity: Call EmblemHealth Customer Service at 1-800-447-8255 to request transportation or fax the Medical Necessity Taxi Transportation Request Form to 1-631-719-0911.
    2. If the Managing Entity is Montefiore (CMO): Call 1-877-447-6668 to request taxi transport, or fax request to 1-914-377-4798. Please note: This does not apply to Medicaid members because we do not cover non-emergency transportation in CMO's service area of New York City and Westchester.

    LDSS' Vendor Contact Information When Transportation Is Covered by Medicaid FFS

    1. Nassau County: EmblemHealth does not cover non-emergency rides for Medicaid members. Members should call Logisticare Solutions at 1-877-813-5602 to request transportation. Providers and members call 1-516-227-8070 for reimbursement.
    2. New York City: EmblemHealth does not cover non-emergency rides for Medicaid members. Members and providers should call Logisticare of New York City at 1-877-564-5922 to request transportation. For Dual Eligible (PPO) SNP, call Human Resources Administration (HRA) at 1-212-630-1810.
    3. Suffolk County: EmblemHealth does not cover non-emergency rides for Medicaid members. Members should call Servisair at 1-866-952-1564 to register and request transportation. Providers call 1-866-952-1564 for reimbursement.
    4. Westchester County: EmblemHealth does not cover non-emergency rides for Medicaid members. These members or their providers should call Medical Answering Services at 1-866-883-7865 to request transportation services.

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    Glossary terms found on this page:

    A health insurance product offered by a health plan company that is defined by the benefit contract and represents a set of covered services. Also called a health benefit plan.

    Services available to a member as defined in his or her contract. Benefit design includes the types of benefits offered, limits (e.g., number of visits, percentage paid or dollar maximums applied) and subscriber responsibility (cost sharing components).

    An itemized statement of health care services and their costs provided by a hospital, physician's office or other health care facility. Claims are submitted to the insurer or managed care plan by either the plan member or the provider for payment of the costs incurred.

    A legal agreement between an individual member or an employer group and a health plan that describes the benefits and limitations of the coverage.

    Means a medical or behavioral condition, the onset of which is sudden, that manifests itself by symptoms of sufficient severity, including severe pain, that a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in (a) placing the health of the person afflicted with such condition in serious jeopardy, or in the case of a behavioral condition, placing the health of such person or others in serious jeopardy; (b) serious impairment to such person’s bodily functions; (c) serious dysfunction of any bodily organ or part of such person; or (d) serious disfigurement of such person.

    A payment method in which the insurer will reimburse the member or provider directly for each covered medical expense.

    A professionally licensed individual, facility or entity giving health-related care to patients. Physicians, hospitals, skilled nursing facilities, pharmacies, chiropractors, nurses, nurse-midwives, physical therapists, speech pathologist and laboratories are providers. All network providers are health care providers, but not all providers are network providers.

    An organization that provides comprehensive health care coverage to its members through a network of doctors, hospitals and other health care providers. Also called a Health Maintenance Organization.

    A city or county social services district as constituted by Section 61 of the New York State Social Services Law (SSL). Also called a Local Department of Social Services.

    A city or county social services district as constituted by Section 61 of the New York State Social Services Law (SSL). Also called a LDSS.

    Acronym for Medicare Advantage. An alternative to the traditional Medicare program in which private plans run by health insurance companies provide health care benefits that eligible beneficiaries would otherwise receive directly from the Medicare program.

    A jointly funded federal and state program that provides hospital and medical coverage to the low-income population and certain aged and disabled individuals.

    A medical or behavioral condition with a sudden onset that manifests itself by symptoms of sufficient severity, including severe pain, that a prudent layperson possessing an average knowledge of medicine and health could reasonably expect the absence of immediate medical attention to result in:

    • Placing the health of the person afflicted with such condition in serious jeopardy, or in the case of a behavioral condition placing the health of such person or others in serious jeopardy
    • Serious impairment to such person's bodily functions
    • Serious dysfunction of any bodily organ or part of such person
    • Serious disfigurement of such person

    Health care that is rendered by a hospital or a licensed or certified provider and is determined by EmblemHealth to meet all of the criteria listed below:

    • It is provided for the diagnosis or direct care or treatment of the condition, illness, disease, injury or ailment.
    • It is consistent with the symptoms or proper diagnosis and treatment of the medical condition, disease, injury or ailment.
    • It is in accordance with accepted standards of good medical practice in the community.
    • It is furnished in a setting commensurate with the member's medical needs and condition.
    • It cannot be omitted under the standards referenced above.
    • It is not in excess of the care indicated by generally accepted standards of good medical practice in the community.
    • It is not furnished primarily for the convenience of the member, the member's family or the provider.
    • In the case of a hospitalization, the care cannot be rendered safely or adequately on an outpatient basis or in a less intensive treatment setting and, therefore, requires the member receive acute care as a bed patient.

    The fact that a provider has prescribed a service or supplies care does not automatically mean the service or supply will qualify for reimbursement under the EmblemHealth plan. To be eligible for reimbursement by EmblemHealth, all covered services must meet EmblemHealth's medical necessity criteria, described above.

    Medically necessary with respect to Medicaid and Family Health Plus members means health care and services that are necessary to prevent, diagnose, manage or treat conditions that cause acute suffering, endanger life, result in illness or infirmity, interfere with a person's capacity for normal activity or threaten some significant handicap.

    A nationwide insurance program for the disabled and people age 65 and over, created by the 1965 amendments to the Social Security Act and operated under the provisions of the Act. It consists of two separate but coordinated programs, Part A and Part B.

    This part of Medicare provides medical surgical benefits for Medicare beneficiaries for a modest premium.

    An individual and each of his or her eligible dependents, including Medicare beneficiaries who are enrolled or participate in a benefit program and who are entitled to receive covered services from the practitioner pursuant to such benefit program and the terms of the practitioner's agreement.

    A family physician, family practitioner, general practitioner, internist or pediatrician who is responsible for delivering or coordinating care. Also called a primary care physician.

    A health plan that offers benefits in-network and out-of-network. In-network services are available to enrollees at lower out-of-pocket cost than the services of non-network providers. In addition, PPO enrollees may self-refer to any network provider at any time. Also called a Preferred Provider Organization.

    A family physician, family practitioner, general practitioner, internist or pediatrician who is responsible for delivering or coordinating care. Also called a PCP.

    The process of obtaining advanced approval of coverage for a health care service or medication. The request for services is reviewed to assess medical necessity and appropriateness of elective hospital admissions and non-emergency outpatient services before the services are provided. Also called pre-authorization or pre-certification or pre-determination.

    A medical practitioner or covered facility recognized by EmblemHealth for reimbursement purposes. A provider may be any of the following, subject to the conditions listed in this paragraph:

    • Doctor of medicine
    • Doctor of osteopathy
    • Dentist
    • Chiropractor
    • Doctor of podiatric medicine
    • Physical therapist
    • Nurse midwife
    • Certified and registered psychologist
    • Certified and qualified social worker
    • Optometrist
    • Nurse anesthetist
    • Speech-language pathologist
    • Audiologist
    • Clinical laboratory
    • Screening center
    • General hospital
    • Any other type of practitioner or facility specifically listed in the member's Certificate of Insurance as a practitioner or facility recognized by EmblemHealth for reimbursement purposes

    A provider must be licensed or certified to render the covered service. The covered service must be within the scope of the Provider's license or certification.

    The geographic area in which a health plan is prepared to deliver health care through a contracted network of participating providers.

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