Nonemergency Wheelchair Van

(A) Criteria for Use. (1) Wheelchair van services may be provided only in nonemergencies to the following persons: (a) MassHealth members who use wheelchairs; (b) MassHealth members who need to be carried up or down stairs (because they are unable to walk up or down stairs or cannot walk without the assistance of two persons); (c) MassHealth members whose severe mobility handicaps prevent them from using public transportation or brokered transportation in a sedan; and (d) MassHealth members who are being transported by a fee-for-service provider, who are being discharged from inpatient psychiatric hospitals to community-based behavioral health programs, and who require supervision during transportation, when PT-1 transportation is unavailable or inappropriate. (2) Fee-for-service wheelchair van services may be provided only in nonemergencies to: (a) MassHealth members meeting the criteria in 130 CMR 407.471(A)(1)(a) through (c) who also reside in institutional settings; (b) MassHealth members meeting the criteria in 130 CMR 407.471(A)(1)(a) through (c) who also reside in the community and need mobility assistance from transportation provider personnel to exit their residences or to move from their residences to the vehicle; and (c) MassHealth members meeting the criteria in 130 CMR 407.471(A)(1)(d). (B) Authorization. Fee-for-service wheelchair van transportation requires a Medical Necessity Form completed in accordance with 130 CMR 407.421(D). Brokered wheelchair van services require a Provider Request for Transportation (PT-1) form completed and approved in accordance with 130 CMR 407.421(C). (C) Recordkeeping Requirement. (1) Providers of fee-for-service wheelchair van services must keep records of all services billed to the MassHealth agency. Such records must be maintained in accordance with 130 CMR 450.205: Recordkeeping and Disclosure and must include a log or trip sheet, separate from the claim form, containing the name of the member transported, the date of service, the origin and destination of the trip, and the vehicle identification number. If two or more persons are transported together, the provider must record the names of all passengers on the log or trip sheet. (2) In areas of the state where a selective contract with a transportation broker is in effect, the recordkeeping requirements in the contract apply for brokered transportation. (D) Rates of Payment. (1) Payment for fee-for-service wheelchair van service is made in accordance with 101 CMR 327.00: Rates of Payment for Ambulance and Wheelchair Van Services.. (2) The service codes that must be used when billing for wheelchair van services are listed in Subchapter 6 of the Transportation Manual. (3) Payment for brokered wheelchair van services will be made in accordance with the terms of the applicable selective contract. (130 CMR 407.472 through 407.480 Reserved.)