Senate Bill No. 763
(By Senators Oliverio, Foster and Bailey)
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[Introduced February 20, 2006; referred to the Committee
on Health and Human Resources; and then to the Committee on
Finance.]
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A BILL to amend the Code of West Virginia, 1931, as amended, by
adding thereto a new section, designated §9-5-20; and to amend
and reenact §16-4C-3 of said code, all relating to
nonemergency vehicle transportation; defining terms; requiring
Medicaid preauthorization for nonmedical transports; and
providing for appeals, recoupment of payments and cancellation
of prior authorizations.
Be it enacted by the Legislature of West Virginia:
That the Code of West Virginia, 1931, as amended, be amended
by adding thereto a new section, designated §9-5-20; and that
§16-4C-3 of said code be amended and reenacted, all to read as
follows:
CHAPTER 9. HUMAN SERVICES.
ARTICLE 5. MISCELLANEOUS PROVISIONS.
§9-5-20. Prior medicaid authorization for nonemergency transport.
(a) If nonemergency services are covered under the state
medicaid plan, upon application by any medicaid benefits recipient,
physician, nurse, medical social worker or any emergency medical
services agency, the Department of Health and Human Resources shall
determine the eligibility and medical necessity of nonemergency
medical transportation services, as defined in section three,
article four-c, chapter sixteen of this code, to the medicaid
patient prior to the receipt of the services. Subject to the
provisions of subsection (b) of this section, the department shall
make a determination of eligibility and medical necessity within
twenty-four hours of receipt of the application and shall advise
the patient and the emergency medical services agency, in writing,
of its decision. If a determination of eligibility and medical
necessity is not made by the department within the required
forty-eight hour period, the service shall be deemed approved and
authorized, and the department shall cover the cost of the
nonemergency transport:
Provided, That this section shall not
apply to patients requiring specialized multi-patient medical
transport as defined in subdivision (t), section three, article
four-c, chapter sixteen of this code.
(b) In the event of a life-threatening situation, or when a
physician orders a medicaid benefits recipient patient transferred
to a facility for a higher level of care, and the patient cannot wait for the forty-eight hour approval period provided in
subsection (a), the transport is presumed to be medically necessary
if medicaid would otherwise pay for the care provided by the
receiving facility.
(c) Once the Department of Health and Human Resources has
approved the eligibility and medical necessity for a medicaid
benefits recipient to receive nonemergency transportation three or
more times within a seven-day period, the medicaid recipient shall
be deemed approved for all nonemergency services provided during
the next sixty-day period or for such longer period as may be
approved by the department. At or near the expiration of the
approved period, the department shall review the eligibility and
medical necessity of the nonemergency transport services provided
and extend or deny further authorization for such services. Any
extension of the authorization shall be for additional sixty-day
periods or for such other longer periods as the department may deem
necessary.
(d) The Department of Health and Human Resources may rescind
prior authorization of nonemergency transport services for a
medicaid patient by notifying the provider of the services and the
patient in writing of the recision of the authorization. The
department shall be responsible for the payment of any authorized
services provided prior to the provider receiving certified written
cancellation of the prior authorization.
(e) Any decision by the Department of Health and Human
Resources to deny prior authorization of nonemergency medical
transports may be appealed by the patient, the patient's personal
representative or family member or the patient's physician, nurse
or medical social worker.
(f) Payments for services that the Department of Health and
Human Resources determines are medically necessary for medicaid
patients and authorizes may not be recouped or reclaimed by the
department once the services are rendered by the provider in good
faith reliance on the prior authorization:
Provided, That this
section does not apply to payment for any services fraudulently
billed or submitted by any provider or patient.
CHAPTER 16. PUBLIC HEALTH.
ARTICLE 4C. EMERGENCY MEDICAL SERVICES ACT.
§16-4C-3. Definitions.
As used in this article, unless the context clearly requires
a different meaning:
(a) "Ambulance" means any privately or publicly-owned vehicle
or aircraft which is designed, constructed or modified; equipped or
maintained; and operated for the transportation of patients,
including, but not limited to, emergency medical services vehicles;
rotary and fixed wing air ambulances; gas kkk-A-1822 federal
standard type I, type II and type III vehicles; and specialized
multi-patient medical transport vehicles operated by an emergency medical services agency;
(b) "Commissioner" means the Commissioner of the Bureau of
Public Health;
(c) "Council" means the Emergency Medical Service Advisory
Council created pursuant to section five of this article;
(d) "Emergency medical services" means all services which are
set forth in Public Law 93-154 "The Emergency Medical Services
Systems Act of 1973" and those included in and made a part of the
emergency medical services plan of the Department of Health and
Human Resources inclusive of, but not limited to, responding to the
medical needs of an individual to prevent the loss of life or
aggravation of illness or injury;
(e) "Emergency medical service agency" means any agency
licensed under section six-a of this article to provide emergency
medical services;
(f) "Emergency medical service attendant" means a person
certified by the commissioner pursuant to the provisions of section
eight of this article to render the services authorized pursuant to
the provisions of section fourteen of this article;
(g) "Emergency medical service personnel" means any person
certified by the commissioner to provide emergency medical services
authorized in section eight of this article and includes, but is
not limited to, emergency medical service attendant, emergency
medical technician-basic and emergency medical technician-paramedic;
(h) "Emergency medical service provider" means any authority,
person, corporation, partnership or other entity, public or
private, which owns or operates a licensed emergency medical
services agency providing emergency medical service in this state;
(i) "Emergency medical technician-basic" means a person
certified by the commissioner pursuant to the provisions of section
eight of this article to render the services authorized pursuant to
the provisions of section fourteen of this article;
(j) "Emergency medical technician-paramedic" means a person
certified by the commissioner pursuant to the provisions of section
eight of this article to render services as authorized pursuant to
the provisions of section fourteen of this article;
(k) "Emergency services" means those services provided in or
by a hospital emergency facility, an ambulance providing related
services under the provisions of this article or the private office
of a dentist to evaluate and treat a medical condition manifesting
itself by the sudden, and at the time, unexpected onset of symptoms
that require immediate medical attention, and that failure to
provide immediate medical attention would result in serious
impairment to bodily function, a serious dysfunction to any bodily
organ or part or would place the person's health in jeopardy.
(k) (l) "Governing body" has the meanings ascribed to it as
applied to a municipality in subdivision (1), subsection (b), section two, article one, chapter eight of this code;
(l) (m) "Line officer" means the emergency medical service
personnel, present at the scene of an accident, injury or illness,
who has taken the responsibility for patient care;
(m) (n) "Medical command" means the issuing of orders by a
physician from a medical facility to emergency medical service
personnel for the purpose of providing appropriate patient care;
(n) (o) "Municipality" has the meaning ascribed to it in
subdivision (1), subsection (a), section two, article one, chapter
eight of this code;
(p) "Nonemergency services" means services provided to a
patient whose condition does not meet the definition for emergency
services or emergency medical services, all scheduled transports,
inter-facility transports or all transports to a nonacute health
care facility.
(o) (q) "Patient" means any person who is a recipient of the
services provided by emergency medical services;
(p) (r) "Service reciprocity" means the provision of emergency
medical services to citizens of this state by emergency medical
service personnel certified to render those services by a
neighboring state;
(q) (s) "Small emergency medical service provider" means any
emergency medical service provider which is made up of less than
twenty emergency medical service personnel; and
(r) (t) "Specialized multi-patient medical transport" means a
type of ambulance transport provided for patients with medical
needs greater than those of the average population, which may
require the presence of a trained emergency medical technician
during the transport of the patient:
Provided, That the
requirement of "greater medical need" may not prohibit the
transportation of a patient whose need is preventive in nature.
NOTE: The purpose of this bill is to require preauthorization
for nonemergency transports for Medicaid patients.
Strike-throughs indicate language that would be stricken from
the present law, and underscoring indicates new language that would
be added.
§9-5-20 is new; therefore, strike-throughs and underscoring
have been omitted.