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Douglas County Department of Health and Human Services (715) 395-1283 (medical transportation 1316 N. 14th Street, Suite 400, Superior, WI 54880 message line) MEDICAL TRANSPORTATION POLICY Medical Transportation MAY be available to current Wisconsin Medical Assistance Recipients. Following, you will find the policies that govern eligibility for reimbursement and Medical Cab service through this program. 1. PRIOR AUTHORIZATION IS REQUIRED FOR ALL non-emergency medical transportation; requests for prior authorization can be made by telephone to the medical transportation line, in person, or in writing. In the case of needed emergency transportation, this agency must be contacted within three working days after the emergency so authorization for the transportation can be issued. Verification that an emergency existed WILL be required to authorize transportation. 2. Transportation can be reimbursed or cab fare paid ONLY from recipients home to the location where a WI Medical Assistance covered service is provided and back to recipient’s home. The covered recipient MUST be in the vehicle for services to be paid. 3. Provider documentation that a covered service was provided WILL be required. NO altered documentation will be accepted. If date and/or time of appointment changes, change must be signed by physician or assistant. 4. Verification of current Medical Assistance coverage MAY be required for those persons not certified by this agency. 5. Reimbursement will be to the NEAREST service provider. If a specialized service at a more distant location is MEDICALLY necessary, WRITTEN DOCUMENTATION WILL BE REQUIRED from the local service provider. If written documentation is not received, reimbursement rate will be to the nearest provider. 6. Only the LEAST expensive means of transportation, which the Medical Assistance recipient can use and which is reasonably available when the service is required. Medical Cab Service is not available for households with vehicle asset. 7. Common carrier (bus, taxi, etc.) will be reimbursed at the actual cost within the limits of #6 above. 8. Other reimbursable costs, in addition to transportation, MAY include the cost of meals and lodging en route to medical care, while receiving medical care and returning from the medical care. PRIOR WRITTEN AUTHORIZATION IS REQUIRED. Documented appointment dates/times (if deemed MEDICALLY necessary for overnight stay). Proximity of (150+ miles) away from recipient’s home to complete needed medical care. Reimbursement will be at the county rate for employees. No advanced lodging/meals. 9. Attendant costs (meals, transportation, lodging, etc.) may be allowed within the following guidelines: • A physician must document the age and physical condition of the Medical Assistance recipient to warrant the need for an attendant. • NO ATTENDANT COSTS CAN BE PAID TO A MEMBER OF THE RECIPIENT’S FAMILY. Reference: (Wisconsin Administrative Code, HSS 107.23(3)(A)2) 10. Medical Mileage Reimbursement can go back a MAXIMUM of three months. 11. NO parking will be paid. IMPORTANT NOTICE(s): Failure to comply with this policy may result in termination of your utilization of the Medical Transportation Program. Beginning March 1, 2007, all clients using taxi cab services for medical appointments will need to submit verification (using an agency Verification Form) for each medical visit at the end of the month for services used that month. *This also includes prescriptions picked up. If verification is not received for each visit by the 5th of the following month, you will be responsible for that months cab fare and you will be put on the “No Ride List.” If verification is received after the 5th of the month, you will remain on the “No Ride List” until the 5th of the following month. *Beginning December 1, 2007, we will no longer reimburse mileage or pay cab fare for prescription(s) pick up unless you have documentation from your physician or pharmacist that your prescription(s) cannot be mailed or delivered directly to your home. Dated/Itemized Receipts are required for reimbursement of meals, lodging, and common carrier. NO receipts will be accepted without ACTUAL date of service, name & location. NO handwritten dates will be accepted. NO altered receipts will be accepted. A SIGNED mileage account (agency form) must be submitted for reimbursement of mileage of a private vehicle BY THE 5TH OF THE MONTH FOLLOWING THE MONTH OF TRANSPORT. All mileage reimbursement requests WILL be returned to sender if not on an agency Mileage Reimbursement form. All mileage reimbursement requests WILL be Map Quested for accuracy and consistency. (You can request forms at the above message line number or stop in this office to pick up forms). Current mileage rate is $0.24 per mile. 1/2009-ram