2936 Exceptional Transportation Services

Georgia State Seal

Georgia Division of Family and Children Services
Medicaid Policy Manual

Policy Title:

Exceptional Transportation Services

Effective Date:

June 2020

Chapter:

2900

Policy Number:

2936

Previous Policy Number(s):

MT 54

Updated or Reviewed in MT:

MT-60

Requirements

The Georgia Department of Community Health, Division of Medical Assistance (DCH/DMA) provides reimbursement for Exceptional Transportation Services for Medicaid members to obtain medically necessary treatment out-of-state when the member is financially unable to provide his/her own transportation.

Basic Considerations

Definition

Exceptional Transportation Services (ETS) is defined as non-emergency medical transportation necessary under extraordinary medical circumstances that require out-of- state travel for treatment not normally provided through in-state medical providers.

Medicaid members enrolled in a Care Management Organization (CMO) must request services covered under the ETS program through their CMO plan and not DFCS.
Meals and lodging may be reimbursed for in-state travel if the treatment is not available through a provider in the member’s region and over 50 miles from the member’s residence. In-state transportation is coordinated by the NEMT broker responsible for the county in which the member resides.

ETS is not available for travel to certain medical providers within fifty (50) miles of the state’s border who are utilized for routine care by individuals living in Georgia’s border counties and to medical facilities that have been designated as exceptions to the fifty-mile limit. Refer to Chart 2936.1 in this Section for a list of these facility exceptions.

DFCS Responsibilities

The DCH/DMA contracts with the Department of Human Services, Division of Family and Children Services (DHS/DFCS) to arrange, coordinate, and provide exceptional transportation services for Medicaid members.

The DFCS state office Medicaid Policy Unit is responsible for:

  • determining the need for ETS;

  • submitting required DMA-322 Exceptional Transportation Prior Authorization Request form to DCH/DMA for approval;

  • notifying the county DFCS office of the DCH/DMA determination, including the prior authorization number.

The DFCS Regional Accounting Office is responsible for:

  • gathering the information necessary for an ETS eligibility determination;

  • notifying the Medicaid member of the ETS decision;

  • providing payment for approved transportation costs.

Eligibility Requirements

ETS is available to Medicaid members only if all the following conditions are met:

  • the member’s out-of-state medical care has been pre-certified by Georgia Health Partnership (GHP);

  • the member is financially unable to pay for his/her transportation costs;

  • the member has no other means of transportation, such as a household member, relative, or friend.

Covered Expenses

Expenses covered by ETS include:

  • automobile mileage

  • parking, tolls

  • taxi service

  • commercial transportation costs (airplane, bus, train)

  • meals

  • lodging

Approval for ETS does not automatically entitle the member to all potentially covered services. The DCH/DMA approval will specify what expenses are approved.

Transportation expenses for an escort may be covered for members who are:

  • under age 21

  • blind

  • deaf

  • intellectually disabled

  • other situations or conditions that preclude travel without an escort

Procedures

Upon receipt of the request for ETS , follow the steps below:

Step 1

Notify the DFCS state office Medicaid Policy Unit via telephone, (404) 657-7543, that ETS services have been requested.
Step 2

Obtain the following information and provide to the DFCS state office Medicaid Policy Unit:

  • pre-certification number for the out-of-state medical services (available from the member’s local or out-of-state medical provider);

  • out-of-state medical provider’s name, address, telephone number, and contact person;

  • member’s name, address, telephone number, date of birth, and Medicaid number;

  • member’s diagnosis and procedure to be performed;

  • member’s explanation of his/her circumstances that justify the request for and approval of ETS.

  • W-9 Form completed by the member or member’s representative.
Step 3

Upon notification from the state office Medicaid Policy Unit, inform the member of the ETS decision.
Step 4

Provide ETS payment(s) to the approved commercial carrier(s) and/or ETS advance to the member according to the DCH/DMA decision.

Reimbursement

To receive reimbursement from DCH for covered ETS expenses, DFCS must complete and submit a HCFA-1500 claim form through the DCH web portal as stated below:

Step 1

Go to the GA MMIS website at www.mmis.georgia.gov/portal. Click on the Provider Information tab, and then click on Documents and Forms. Click on full list and click on CMS1500. Print as many copies as you need.
Step 2

To obtain instructions on how to submit a claim, please reference the ETS Policies and Procedures Manual (Appendix F) which can be downloaded at www.mmis.georgia.gov. For information on how to navigate the web portal, you may download a copy of the Navigational Manual for Providers.
Step 3

In order to request reimbursement through the web portal you must be registered. If the Regional Office is not registered, contact the Medicaid Policy Unit at (404) 657-7543 to obtain a copy of the Web Portal Registration form. This form needs to be completed and faxed to DXC at the number listed on the form. Any billing problems should be addressed with the counties' local DXC Provider Field Representative.
Chart 2936.1 – Participating Non-Georgia Hospitals
Alabama

Flowers General

Dothan

George H. Lanier

Langdale

Lakeview Community

Eufaula

Southeast Alabama Medical Center

Dothan

Phenix Regional

Phenix City

Stringfellow Memorial

Anniston

Florida

Baptist Medical Center

Jacksonville

Baptist Medical Center-Nassau

Fernandina Beach

Ed Fraser Memorial

Macclenny

Saint Vincent’s

Jacksonville

Shands - University of Florida

Gainesville

Tallahassee Community

Tallahassee

Tallahassee Memorial Regional Medical Center

Tallahassee

University Medical Center

North Carolina

Angel Community

Franklin

District Memorial

Andrews

Harris Regional

Sylva

Highland Cashiers

Highland

Murphy Medical Center

Murphy

South Carolina

Abbeville County Memorial

Abbeville

Allen Bennett Memorial

Greenville

Anderson Area Medical Center

Anderson

Greenville Memorial

Greenville

Hillcrest

Greenville

Aiken Regional

Aiken

Tennessee

Bradley Memorial

Cleveland

Chattanooga Rehabilitation

Chattanooga

Cleveland Community

Cleveland

Copper Basin

Copper Hill

East Ridge

Chattanooga

Erlanger Medical Center

Chattanooga

Grandview Medical Center

Jasper

Memorial

Chattanooga

Parkridge Medical Center

Chattanooga

T.C. Thompson Children’s

Chattanooga

Siskin

Chattanooga