DHS 107.23(2)(d)(d) Trips by ambulance to obtain physical therapy, occupational therapy, speech therapy, audiology services, chiropractic services, psychotherapy, methadone treatment, alcohol abuse treatment, other drug abuse treatment, mental health day treatment or podiatry services;

DHS 107.23(2)(f)(f) All SMV transportation to receive MA-covered services, except for services to be received out of state for which prior authorization has already been received, that is over 40 miles for a one-way trip in Brown, Dane, Fond du Lac, Kenosha, La Crosse, Manitowoc, Milwaukee, Outagamie, Sheboygan, Racine, Rock and Winnebago counties from a recipient’s residence, and 70 miles for a one-way trip in all other counties from a recipient’s residence.

DHS 107.23(3)(a)1.1. When a hospital-to-hospital or nursing home-to-nursing home non-emergency transfer is made by ambulance, the ambulance provider shall obtain, before the transfer, written certification from the recipient’s physician, physician assistant, nurse midwife or nurse practitioner explaining why the discharging institution was not an appropriate facility for the patient’s condition and the admitting institution is appropriate for that condition. The document shall be signed by the recipient’s physician, physician assistant, nurse midwife or nurse practitioner and shall include details of the recipient’s condition. This document shall be maintained by the ambulance provider.

DHS 107.23(3)(a)2.2. If a recipient residing at home requires treatment at a nursing home, the transportation provider shall obtain a written statement from the provider who prescribed the treatment indicating that transportation by ambulance is necessary. The statement shall be maintained by the ambulance provider.

DHS 107.23(3)(a)3.3. For other non-emergency transportation, the ambulance provider shall obtain documentation for the service signed by a physician, physician assistant, nurse midwife, dentist or nurse practitioner. The documentation shall include the recipient’s name, the date of transport, the details about the recipient’s condition that preclude transport by any other means, the specific circumstances requiring that the recipient be transported to the office or clinic to obtain a service, the services performed and an explanation of why the service could not be performed in the hospital, nursing home or recipient’s residence. Documentation of the physician, dentist, physician assistant, nurse midwife or nurse practitioner performing the service shall be signed and dated and shall be maintained by the ambulance provider. Any order received by the transportation provider by telephone shall be repeated in the form of written documentation within 10 working days of the telephone order or prior to the submission of the claim, whichever comes first.

DHS 107.23(3)(a)4.4. Services of more than the 2 attendants required under s. 256.15 (4), Stats., are covered only if the recipient’s condition requires the physical presence of more than 2 attendants for purposes of restraint or lifting. Medical personnel not employed by the ambulance provider who care for the recipient in transit shall bill the program separately.

DHS 107.23(3)(a)5.5.

DHS 107.23(3)(a)5.a.a. If a recipient is pronounced dead by a legally authorized person after an ambulance is requested but before the ambulance arrives at the pick-up site, emergency service only to the point of pick-up is covered.

DHS 107.23(3)(a)5.b.b. If ambulance service is provided to a recipient who is pronounced dead enroute to a hospital or dead on arrival at the hospital by a legally authorized person, the entire ambulance service is covered.

DHS 107.23(3)(a)6.6. Ambulance reimbursement shall include payment for additional services provided by an ambulance provider such as for drugs used in transit or for starting intravenous solutions, EKG monitoring for infection control, charges for reusable devices and equipment, charges for sterilization of a vehicle including after carrying a recipient with a contagious disease, and additional charges for services provided at night or on weekends, or on holidays. Separate payments for these charges shall not be made.

DHS 107.23(3)(a)7.7. Non-emergency transfers by ambulance that are for the convenience of the recipient or the recipient’s family are reimbursed only when the attending physician documents that the participation of the family in the recipient’s care is medically necessary and the recipient would suffer hardship if the transfer were not made by ambulance.

DHS 107.23(3)(b)1.1. Transportation by SMV shall be covered only if the purpose of the trip is to receive an MA-covered service. Documentation of the name and address of the service provider shall be kept by the SMV provider. Any order received by the transportation provider by telephone shall be repeated in the form of written documentation within 10 working days of the telephone order or prior to the submission of the claim, whichever comes first.

DHS 107.23(3)(b)2.2. Charges for waiting time are covered charges. Waiting time is allowable only when a to-and-return trip is being billed. Waiting time may only be charged for one recipient when the transportation provider or driver waits for more than one recipient at one location in close proximity to where the MA-covered services are provided and no other trips are made by the vehicle or driver while the service is provided to the recipient. In this subdivision, “waiting time” means time when the transportation provider is waiting for the recipient to receive MA covered services and return to the vehicle.

DHS 107.23(3)(b)3.3. Services of a second SMV transportation attendant are covered only if the recipient’s condition requires the physical presence of another person for purposes of restraint or lifting. The transportation provider shall obtain a statement of the appropriateness of the second attendant from the physician, physician assistant, nurse midwife or nurse practitioner attesting to the need for the service and shall retain that statement.

DHS 107.23(3)(b)4.4. SMV services may only be provided to recipients identified under sub. (1) (c).

DHS 107.23(3)(b)5.5. A trip to a sheltered workshop or other nonmedical facility is covered only when the recipient is receiving an MA-covered service there on the dates of transportation and the medical services are of the level, intensity or extent consistent with the medical need defined in the recipient’s plan of care.

DHS 107.23(3)(b)6.6. Trips to school for MA-covered services shall be covered only if the recipient is receiving services on the day of the trip under the Individuals with Disabilities Education Act, 20 USC 33, and the MA-covered services are identified in the recipient’s individual education plan and are delivered at the school.

DHS 107.23(3)(b)7.7. Unloaded mileage as defined in sub. (1) (c) 5. is not reimbursed if there is any other passenger in the vehicle whether or not that passenger is an MA recipient.

DHS 107.23(3)(b)8.8. When 2 or more recipients are being carried at the same time, the department may adjust the rates.

DHS 107.23(3)(b)9.9. Additional charges for services at night or on weekends or holidays are not covered charges.

DHS 107.23(3)(b)10.10. A recipient confined to a cot or stretcher may only be transported in an SMV if the vehicle is equipped with restraints which secure the cot or stretcher to the side and the floor of the vehicle. The recipient shall be medically stable and no monitoring or administration of non-emergency medical services or procedures may be done by SMV personnel.

DHS 107.23(3)(c)1.1. Non-emergency transportation of a recipient by common carrier is subject to approval by the county or tribal agency or its designee before departure. The reimbursement shall be no more than an amount set by the department and shall be less per mile than the rates paid by the department for SMV purposes. Reimbursement for urgent transportation is subject to retroactive approval by the county or tribal agency or its designee.