Consistent and reliable patient access to care is essential for patient wellness and chronic care management. Non- emergency medical transportation (NEMT) includes transportation services offered to patients who face barriers getting to their medical appointments. Those barriers can include not having a valid driver’s license, not having a working vehicle in the household, being unable to travel or wait for services alone, or having a physical, cognitive, mental, or developmental limitation.

NEMT services are intended for medical appointments or other forms of non-emergency care. Non-emergency medical transportation differs from emergency transportation in that NEMT is intended:

• For members’ whose medical need is NOT immediate. Symptoms are neither severe, life-threatening (e.g., a heart attack), nor due to a serious event (e.g., a car accident); AND
• To ensure members are able to attend necessary medical appointments; AND
• To ensure the most appropriate mode of transportation is used for the Member’s health condition.

Depending on the Member’s medical condition, non-emergency ambulance transportation (air or ground) may or may not be appropriate. In addition to non-emergency ambulance services, other modes of transportation covered by NEMT are listed below.

Stretcher Van:

Rides for patients who are bed-bound or who must travel while lying down. Vehicles are equipped with gurneys/stretchers and specialized equipment.

Wheelchair Van:

Rides for patients who must travel in their wheelchair. Vehicles are specially equipped for accessibility. These vehicles may also be referred to as Ambulettes, Ambi-Buses, or Mobility Assistance Vehicles.

Door-to-Door:

Rides for ambulatory patients who need help getting from their home or medical appointment to the vehicle and vice versa.

These alternative modes of transportation are not considered the same as ambulance transportation, even if provided by an ambulance company, and may not be used interchangeably with ambulance transportation. Medicare covers ambulance services only for beneficiaries whose medical condition is such that use of any other means of transportation is contraindicated. The beneficiary’s condition must require both the ambulance transportation itself and the level of service provided in order to be considered medically necessary.

Note: Prior authorization from Harvard Pilgrim StrideSM (HMO) Medicare Advantage is required for ALL non-emergency medical transportation (NEMT), with the following exceptions:

• Ambulance transportation (air or ground) when both the origin and destination modifiers are H. See Table 1 for accepted types of facilities for this modifier.
• Ambulance transportation (air or ground) when the origin modifier is H and the destination modifier is N, or vice versa. See Table 1 for accepted types of facilities for these modifiers.
• Curb-to-curb (C2C) transportation when covered by the Member’s plan as a supplemental benefit.

Note: C2C transportation covers rides for ambulatory patients who do not need help getting from their home or medical appointment to the vehicle and vice versa. Not all Harvard Pilgrim StrideSM (HMO) Medicare Advantage plans offer C2C transportation services. Please refer to the Member’s plan-specific documents (i.e., Evidence of Coverage and Transportation Flyer).

Prior authorization is not required for emergency transportation services that are reasonable and medically necessary to ensure the Member’s safe passage to the nearest medical provider capable of furnishing emergency care.

Harvard Pilgrim StrideSM (HMO) Medicare Advantage does not review or deny coverage for transportation provided to a member in a medical emergency.

Note: For emergency air transport (i.e., airplane or helicopter) Harvard Pilgrim StrideSM (HMO) Medicare Advantage accepts post-service notification (confirming the emergent nature of the situation) to facilitate appropriate claims payment.

Clinical Guideline Coverage Criteria

Harvard Pilgrim Health Care uses guidance from the Centers for Medicare and Medicaid Services (CMS) for coverage determinations for its Medicare Advantage plan members. CMS National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs), Local Coverage Articles (LCAs) and documentation included in the Medicare manuals are the basis for coverage determinations where available. Medicare Benefit Policy Manual Chapter 10- Ambulance Services is being supplemented to provide additional detail regarding medical necessity for its Medicare Advantage plan members. For the service of Medical Transport, evidence is sufficient for coverage. In addition to the criteria in the Medicare Benefit Policy Manual for non-emergency medical transport via ambulance, evidence is also sufficient for the use of wheelchair vans and stretcher vans as a form of medical transportation to ensure access to safe and reliable transportation options. The use of this supplemented criteria in the utilization management process will ensure access to evidence based clinically appropriate care. See References section below for all evidence accessed in the development of these criteria.

Non-Ambulance NEMT for Wheelchair Vans and Stretcher Cars

Non-ambulance modes of non-emergency medical transportation (NEMT) are ideal for patients who are not in immediate danger but do require assistance walking or getting into or out of the vehicle. Personal assistance includes opening and closing doors; moving stretchers, wheelchairs, or other medical equipment; transferring to a vehicle from a wheelchair, and vice versa, or otherwise aiding the patient in ambulating; removing obstacles that could hinder safe movement; and help climbing or descending stairs.

These alternative modes of NEMT (door-to-door, wheelchair van, and stretcher van) may be covered when Harvard Pilgrim StrideSM (HMO) Medicare Advantage determines the member could be safely transported without an ambulance. Members eligible for non-ambulance NEMT are those who require transportation from or to any of the locations listed in Table 3 AND:

1. Are unable to ambulate with or without assistance; OR
2. Are unable to ambulate with or without an assistive device; OR
3. Require assistance getting into, or out of, a vehicle.

Medical Transportation

Harvard Pilgrim StrideSM (HMO) Medicare Advantage only covers non-ambulance NEMT from origins or to destinations listed in Table 3. Even when medical necessity criteria are otherwise met, if the locations requested do not appear in Table 3, Harvard Pilgrim StrideSM (HMO) Medicare Advantage will not cover the non-ambulance NEMT.

Limitations

Harvard Pilgrim StrideSM (HMO) Medicare Advantage considers non-emergency, ground or air, medical transportation (NEMT) as not a covered benefit when:

1. An alternate mode of transportation (e.g., taxicab, public transportation, personal car) is available; OR
2. Mode of transportation is not in accordance with applicable local, state, and federal regulatory, certification, and licensing requirements; OR
3. Medical personnel present during transport are not in accordance with applicable local, state, and federal regulatory, certification, and licensing requirements.

Codes