Idaho Non-Emergency Medical Transportation

Abuse: Practices that are inconsistent with sound fiscal or business practices and result in an unnecessary cost to the Medicaid program, or in reimbursement for services that were not performed.

Accident: Any mishap involving a  transportation provider’s vehicle and a member. This includes, but not limited to, a fender bender, blown tire, etc.

Action: The denial or limited authorization of a requested service, including the type or level of service; the reduction, suspension, or termination of a previously authorized service; the denial in whole or in part of payment for a service; or the failure of the member to act within established time requirements for service accessibility. An action may also be referred to as an adverse benefit determination.

Additional Member: An eligible member beyond the first member transported by a transportation provider during the same trip to healthcare appointments.

Additional Stop: An additional stop (pick-up or drop-off point) other than the initial pick-up and drop-off points. Additional stops occur when multiple members are transported during a single trip or MTM approves an additional trip, i.e. pharmacy stop after a healthcare appointment.

Adverse Benefit Determination: The denial or limited authorization of a requested service, including the type or level of service; the reduction, suspension, or termination of a previously authorized service; the denial in whole or in part of payment for a service; or the failure of the member to act within established time requirements for service accessibility. An adverse benefit determination may also be referred to as an action.

Alternative Method of Transportation: If the most appropriate type of transportation for a member is not available, a different form may be used, i.e. mileage reimbursement in place of a transportation provider.

Ambulance: A vehicle for transporting the sick and injured that is equipped and staffed to provide medical care during transit.

Ambulatory: A person who can walk without the assistance of another person. The person may be using a device such as cane or walker. Ambulatory also includes a person who uses a wheelchair and is able to transfer from the chair to a vehicle.

Ancillary Services: Additional services provided such as parking, meals and lodging, also known as Prior Authorization services.

Appeal: Any written or oral communication by a member or his/her representative to MTM expressing dissatisfaction with the provision of transportation or any other transportation related service provided for under this contract.

Appropriate Method of Transportation: The least expensive mode of transportation that best meets the physical, medical, or behavioral circumstances of a member requiring transportation to a healthcare service.

Assistance: The acts required to physically help a member from, within, or into a building or from, within, or into the medical provider’s site. Without this assistance, it would be unsafe or impossible for the member to reach the vehicle or the medical provider’s site. An employee of the transportation provider, the driver, or an additional person provides this assistance, which is beyond a door-to-door service.

Attendant: Someone who must accompany a member to and from a medical appointment, i.e. family member or aide. An attendant may also be referred to as an escort.

Available Transportation: A public transportation system, transportation provider, organization, agency, or individual offering appropriate transportation services to a member who requires transportation.

Broker: An entity that recruits and contracts with transportation providers; performs payment administration, gate keeping, and verification of need; makes reservations and trip assignments; performs quality assurance and service improvement activities; provides administrative oversight; and reports on NEMT program activities.

Client: Refers to the customer contracted with MTM to handle the transportation benefit offered to their covered population.

Complaint: Any written or verbal expression of dissatisfaction about services, procedures, or functions of MTM which causes an intervention by MTM for the member and/or caller.

CCR: Refers to Customer Care Representative, or an MTM employee who helps members schedule NEMT services. May also be referred to as a CSR or Customer Service Representative.

Curb-to-Curb Transportation: The transportation provider picks up and drops off the member at the curb or outside of the building of the destination.

Door-to-Door Transportation: The transportation provider accompanies the member from the door of the pick- up point to the door of the destination.

Door-through-Door Transportation: The transportation provider accompanies the member from inside their place of residence into the office of the service provider because of a specified physical or mental impairment. This level of service may also be referred to as hand-to-hand.

Driver Trip Log: A form filled out by drivers that records required information for each trip.

Emergency: A situation or medical condition (including labor and delivery) manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could result in seriously jeopardizing the member’s health, impair bodily functions, or cause dysfunction of any bodily organ or part. Emergency transportation is not included in this contract.

Escort: Someone who must accompany a member to and from a medical appointment, i.e. family member or aide.

Follow-Up Treatment: Repeat visits for healthcare services, i.e. further tests based on an appointment.

Fraud: An intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person. It includes any act that constitutes fraud under applicable Federal or State law.

Gas Mileage Reimbursement (GMR): Reimbursement provided to a member, or a member’s friend or family member, for driving to a covered healthcare service. Reimbursement is provided on a per mile basis.

Grievance: An expression of dissatisfaction about any matter. Possible subjects for complaints include, but are not limited to, aspects of interpersonal relationships such as rudeness of a transportation provider or MTM employee, or failure to respect the member’s rights.

Hand-to-Hand Transportation: The transportation provider accompanies the member from inside their place of residence into the office of the service provider because of a specified physical or mental impairment. This level of service may also be referred to as door-through-door.

Healthcare Provider: Any business entity or individual providing one or more healthcare services to a member.

Incident: Any non-vehicular mishap involving a member while in the care of a MTM transportation provider. This includes, but not limited to, the passenger falling while trying to enter the vehicle, a passenger falling while walking to the vehicle, etc.

Level-of-Need (LON) Assessment: Medical assessment completed by the member’s physician and an MTM Care Manager that determines the most appropriate, least costly mode of transportation for each member.

Long Distance Trip: Any trip more than 200 miles one-way, any trip more than 100 miles out-of-state, and some trips 25-100 miles out-of-state based on MTM discretion. MTM must approve long distance trips in advance.

Member: Refers to the Medicaid population served by MTM’s client(s).

MTM Client: Any business entity for which MTM has agreed to provide transportation services.

MTM Passenger: The member who receives the transportation service.

MTM Provider: The contracted transportation provider performing transportation services.

Multi-Passenger Vehicle: A sedan or van type vehicle capable of carrying multiple passengers that is used to transport ambulatory patients who may require assistance.

NEMT (Non-Emergency Medical Transportation): A program that offers non-emergency transportation services for members who have no other means of transportation, but need to secure necessary healthcare services with the nearest healthcare provider.

NEMT Trip: A one-way transportation service from the member’s home to a place where a covered healthcare service will be provided to that member, a return trip home, or a trip from one covered medical service to another.

Network Providers: Transportation providers under contract with MTM.

Non-Ambulatory: A member who cannot walk without assistance and may be in a wheelchair or needs personal assistance.

Non-Emergency Ambulance Trip: A pre-arranged ambulance trip that is not responding to an emergency injury or illness. These services may be needed because a member requires medical care during transit, which an ambulance is equipped and staffed to provide. Ambulance service is not included in this contract.

No-Show: When a member fails to use an approved transportation service that is not cancelled, or when a transportation provider has not cancelled a scheduled trip but fails to complete the scheduled trip.

Private Transportation: Transportation in a vehicle owned by a member or a friend, relative, acquaintance, or other individual, provided the vehicle is not licensed for commercial carriage. Individual does not mean communities, companies, corporations, societies, or associations.

Round Trip: The dispatching of a vehicle to the member’s pick-up point, transporting the member to a medical provider, and transporting the member back to the pick-up point.

Serious Accident/Incident: Any report of death; allegation of abuse or neglect; serious physical injury; improper use of restraints; suicide attempt or threat; or a missing person.

Serious Complaint: Involves complaints such as those of sexual harassment, discrimination, threatening conversation/behavior, safe driving issues, etc.

Shared Ride/Multiload: A form of transportation in which the provider transports several members who have similar or close delivery destinations at the same time.

Special Populations: Includes dialysis, disabled or impaired individuals, the medically fragile members of Adult Day Healthcare, and certain other persons and must take into particular account the physical or medical condition of the rider following certain treatment or activity.

Substantial Complaint: A request for review of the denial or limited authorization of a requested transport; the reduction, suspension, or termination of a previously authorized transport; the denial, in whole or in part, of payment for a transport; the failure to provide transportation services in a timely manner; or the failure to act within the timeframes provided in the contract.

Transportation Provider Profile: A set of data describing each transportation provider’s unique service abilities such as hours of operation, types of vehicles and related transportation services, and pricing structure.

Transportation Provider Service Agreement: The signed written contractual agreement between MTM and the provider of transportation services.

Unsubstantiated Complaint: A complaint that, after full investigation is completed, the transportation provider is found to be in compliance with MTM’s Transportation Provider Guidelines.

Warm Transfer: Transferring a call from a member to their designated Health Plan, per member contract requirements. The Quality Service Representative (QSR) will stay on the line until they have reached a live person.

Urgent Trip: An unscheduled episodic situation in which there is no immediate threat to life or limb, but the member must be seen on the day of the request and treatment cannot be delayed until the next day. This may also include hospital discharges.

Waste: Over-utilization of services or other practices that result in unnecessary costs. Waste is generally not considered to be caused by criminally negligent actions but rather the misuse of resources.

Wheelchair (Paralift) Vans: A vehicle used exclusively for the transportation of non-ambulatory patients. Paralift transports individuals who require transport while sitting in a wheel chair.

Wheelchair Vans: A vehicle that has been designed with a drop floor, extended roof, and ramp or lift to transport disabled members who are in wheelchairs.