Provider Manual

The NETSPAP Online Reference Manual was written to educate and train Medical and Transportation providers to comply with the NETSPAP Program as defined by HFS.  If you want to download a printable version of this manual please click here. Please be advised, there may be updates to this manual at a future time which will be posted at this site.

 

Introduction

Purpose of this Manual

The purpose of this training manual is to outline HFS’ policies in processing Prior Authorizations as they pertain to First Transit and the NETSPAP. It is not inclusive of all policies. Requests are handled on a case-by-case basis and information is subject to change. It is the provider’s responsibility to contact First Transit’s for updated information.

HFS

The Illinois Department of Healthcare and Family Services

The Illinois Department of Healthcare and Family Services, or HFS, administers and funds, in part or in full, Medicaid and other Medical Assistance Programs providing comprehensive health coverage to over 2.7 million qualified adults and children of Illinois.

Detailed information regarding these programs can be obtained at http://www.illinois.gov/hfs/Pages/default.aspx.

NETSPAP

The Non-Emergency Transportation Services Prior Authorization Program 

HFS allows for the provision of Non-Emergency Transportation services of certain Medicaid Participants to their qualified non-emergency medical appointments. In order to ensure these Non-Emergency Transportation Services meet federal guidelines and that reimbursement for these services is free of waste, fraud and abuse, HFS created the NETSPAP; the program was implemented in Cook County in 2001 and statewide in 2004. Since then, the NETSPAP has resulted in multimillion dollar savings for the State of Illinois.

FIRST TRANSIT

First Transit has been contracted to administer the NETSPAP. We issue an approval or denial for a request for coverage of NET services, based on the current guidelines provided by HFS. These Non-Emergency Transportation services must be primarily submitted prior to the Non-Emergency Transportation services being provided. For each request that is entered into the First Transit’s computer system, a Request Tracking Number (RTN) is generated. The requests are then adjudicated, that is, approved, denied, or cancelled. If the request is approved, the NET provider may later submit a claim for reimbursement to HFS.

Please note: First Transit is not involved in the process of enrolling providers or processing reimbursement for their services.

Healthcare and Family Services                                                       IMPACT Provider Enrollment Services
PO Box 19114,
Springfield, IL 62794-9114
Phone: (877) 782-5565 (Option 1)
Email: hfs.PPU@illinois.gov

We encourage all medical and NET Providers to review the Handbook for Providers of Medical Services – Chapter 100 (http://www.illinois.gov/hfs/MedicalProviders/Handbooks/Pages/Chapter100.aspx) and the Handbook for Providers of Transportation Services – Chapter T-200 ( http://www.illinois.gov/hfs/MedicalProviders/Handbooks/Pages/Chapter200.aspx)

For assistance with billing questions or concerns, providers may contact the Illinois Department of Healthcare Family Services at (877) 782-5565.

 

A. Communicating with First Transit

Providers may communicate with First Transit in four ways:

1. Phone

First Transit has two toll-free numbers and a teletypewriter (TTY) for the hearing and/or speech impaired.

Provider Line: (866) 503-9040
Participant Line: (877) 725-0569
TTY: (630) 873-1449

2. Fax (630) 873-1450

First Transit’s fax is ready to receive Non-Emergency Transportation requests and supporting documentation 24 hours a day, 7 days a week, 365 days a year.

All information received by First Transit is recorded and can be retrieved if provided with 1) the sending fax number, 2) the date and time of the transmittal, as shown on the confirmation page, and 3) the type of request. All documentation received by First Transit must be complete, accurate, and legible.

3. Mail

First Transit, Inc
799 W. Roosevelt Road,
Building 4, Suite 200
Glen Ellyn, IL 60137

4. netspap.com

First Transit’s Informational website contains:

Links to HFS
Training Presentations
Non-Emergency Transportation Request and Supporting Forms
Private Auto Enrollment Information
Ambulance Non-Emergency Transportation Procedures and Forms
A Link to PassPORT

A.1 PassPORT

PassPORT is a free web-portal developed by First Transit for use with NETSPAP. It enables Participants and certain providers (currently Long Term Care Facilities, Dialysis Centers, and NET Providers) to view the approved, denied, and pending requests as stored in the ADEPT prior authorization system and to submit Single Trip and Standing Prior Authorizations (SPAs) requests.

PassPORT can be accessed by clicking on the “PassPORT” Tab at www.netspap.com or by going directly to https://www.ft-passport-il.com. PassPORT is available 24 hours a day, 7 days a week, 365 days a year and there is no limit on the number of transactions allowed. PassPORT allows Providers to organize and access Participant information and there is no waiting to talk to a Customer Service Representative.

To create a PassPORT account:

  1. Click on the “Request a New Account” link.
  2. Enter the information requested. Once you select a Provider type, you will be asked to provide your Medicaid Provider ID. This is the 12-digit number you use to bill Illinois Medicaid.
  3. Click on the “Submit request” button. You will receive a response by email.

Please visit https://www.netspap.com/for-providers/passport/ for a detailed PassPORT user guide.

A.2 What You Should Know About First Transit

Customer Service

  • Live Customer Service Representatives are available Monday through Friday, 8 a.m. to 5 p.m. Central Standard Time, except for the following holidays:

New Year’s Day
Martin Luther King’s Birthday
Memorial Day
Independence Day
Labor Day
Thanksgiving Day
Day after Thanksgiving
Christmas Day

  • All inbound and outbound calls are recorded for quality and training purposes.
  • All conversations with Providers must be conducted in English.
  • A Spanish language line is available for Participants. A translator service is used for Participants who speak any other languages, at no cost to the Participant.
  • Transactions are limited to one per NET Provider per call and five to all other Providers.
  • First Transit is not allowed to discuss mileage or payment with any caller.
  • The terms prior approval and prior authorization are interchangeable.

Health Insurance Portability And Accountability Act (HIPAA)

  • Confidentiality is a requirement of First Transit, HFS, and HIPAA. HIPAA is a federal law enacted in 1996. It establishes regulations for the use and disclosure of Protected Health Information (PHI). Per HIPAA, PHI can only be shared between the Participant, their medical provider, HFS, and individuals authorized by the Participant. As a business agent to HFS, First Transit is allowed to access PHI.

Medical Providers may contact First Transit to receive a copy of our “HIPAA Letter”, detailing our relationship to HFS and HIPAA.

  • First Transit must adhere to HIPAA regulations. Therefore, family members and some other representatives calling on behalf of the Participant may be required to furnish verbal or written authorization from the Participant before a request can be processed. Written authorizations should include the Participant’s Recipient Identification Number (RIN), name, signature and the full name of the authorized person.

Medicaid and First Transit

  • First Transit is not involved with providing Medicaid to individuals. We authorize or deny Non-Emergency Transportation requests for those who already have obtained benefits through the Department of Human Services (DHS) office.
  • Once an individual is approved for Medicaid, they receive a Mediplan card and are assigned a Recipient Identification Number (RIN). A RIN is a unique 9-digit number (not a Social Security number) located on the Participant’s medical card. First Transit will only use the RIN or a Request Tracking Number (RTN) to access a Participant’s account.

 

B. Defining Prior Authorization

Non-emergency transportation requests should be submitted prior to the transport taking place. First Transit recommends 5 business days. If extenuating circumstances prevent the Participant or the Provider to obtain prior authorization approval, post-approval may be requested no later than 20 business days after the transport.

Extenuating circumstances include transports that took place after hours and/or urgent trips. Urgent trips include hospital admits, hospital discharges, dialysis trips, SASS trips, emergency room visits with a validated doctor’s referral, or trips where Participants, NET Providers, or Providers could not request prior authorizations during regular business hours. When determining the 20 business days do not include holidays or weekends. The day after the trip is counted as day 1.

Please note:

  • Post approval cannot be requested for Exceptional Modes of Transport, long distance and/or negotiated rate requests.
  • First Transit will only authorize non-emergency transports to the Emergency room if the participant has been referred by a doctor and this referral can be validated by First Transit.
  • Post approvals can be requested over 20 business days for Dialysis Standing Prior Authorizations (SPAs).

Corrections

Corrections are requests for a change to a previously adjudicated trip (due to a First Transit error) and do not fall under the 20 business day rule.
Corrections are reviewed on a case by case basis.

 

C. Criteria for Authorization

In order for First Transit to approve a request for Non-Emergency Transportation, the following criteria must be met:

  1. The Participant must have Medicaid eligibility on the Date of Service
  2. The Participant must be traveling to a scheduled medical appointment (not shopping, or to work)
  3. The Participant must have no other way to get to their medical appointment ( no access to cost-free modes of Non-Emergency Transportation)
  4. The Participant must be transported in the least expensive mode of Non-Emergency Transportation, referred to at times as Category of Service (COS), that can safely transport the Participant on the Date of Service, and if appropriate, approved with an employee or non-employee attendant.
  5. The Participant must be transported by a NET Provider enrolled for the appropriate COS.
  6. The Participant must be transported to the closest appropriate provider.
  7. The Participant must be receiving a covered medical service.

C.1 Medicaid Eligibility

A Participant must have Medicaid eligibility on the date of transport. The NET Provider is responsible for checking said eligibility prior to agreeing to the transport and, when applicable, makes sure spenddown has been met.

Please visit http://hfs.illinois.gov/html/013013n.html for the 1/30/2013 informational notice on the HFS Medical Card, and instructions on how to verify a Participant’s medical eligibility.

HFS Pending Applicants

HFS Pending Applicants are individuals who have applied for Medicaid but their application has not yet been approved. Because these applicants have no RIN, First Transit cannot generate a Request Tracking Number (RTN) and therefore cannot process their request.

If the NET Provider chooses to transport the Participant, they may be able to request post approval timeliness exception through HFS’ Illinois Department of Healthcare Family Services at (877) 782-5565 when and if Medicaid is approved. See the Handbook for Providers of Transportation Services – Chapter T-200, located at http://www.illinois.gov/hfs/MedicalProviders/Handbooks/Pages/Chapter200.aspx, for additional details on what constitutes a post-approval exception.

Managed Care Organizations (MCO)

Participants enrolled with a Managed Care Organization (MCO) have prepaid health services. The MCO may be a Health Maintenance Organization (HMO) or a Managed Care Community Network (MCCN).

Some MCOs cover all medical services and Non-Emergency Transportation for their members. Others cover everything with the exception of dental, optical, and family planning services. First Transit will accept  requests for these excluded services for an eligible Participant who is covered under an MCO, and meets the prior authorization requirements.

Early Intervention Services

Early Intervention Services included in Individual Family Service Plans (IFSP), a) are established by a Child and Family Connections Caseworker, b) are for children 0-3 years old with developmental problems, c) often include diagnostic testing, physical therapy, speech therapy, and others, and d) are not covered by Medicaid.

First Transit may deny Non Emergency Transportation requests to Early Intervention Services; the Family Connections Case Worker should be contacted to arrange Non-Emergency Transportation to the Participant’s appointment.

C.2 Scheduled Medical Appointments

In order for a Participant to be approved for Non-Emergency Transportation services, they must need a ride to a scheduled medical appointment. First Transit cannot approve transport to a facility if there is no medical appointment scheduled.

If a medical facility only takes walk-ins, First Transit must validate that the medical provider only takes walk-ins prior to approving the trip.

First Transit cannot approve transport to non-medical appointments, such as the grocery store, school, church, or a friend’s house.

However, if the Participant has been approved for transport to a covered medical service, they can be dropped off at a non-medical facility instead of home, or be picked up from a non-medical facility if the distance is comparable. These requests will be reviewed by First Transit on a case-by-case basis.

C.3 Cost-Free Modes Of Non-Emergency Transportation

Having Medicaid eligibility does not automatically entitle a Participant for Non-Emergency Transportation services through First Transit. Non-Emergency Transportation is provided to those Participants who have no other means to get to their medical appointment.

If a Participant has never used our services or has not been approved for a trip within 6 months, their access to Cost-Free Non-Emergency Transportation must be assessed. Some examples of Cost-Free Non-Emergency Transportation may include transportation that can be safely provided by a Participant, friend, guardian, or relative, and fixed route transportation.

First Transit may request documentation from a medical provider to support an upgrade in the requested mode of transportation or Category of Service.

When requesting prior authorization on behalf of the Participant, providers must present First Transit with the following information:

  • How the Participant had been transported in the past
  • The reason the Participant is unable to use this method for their appointment
  • The reason, medical or otherwise, the Participant is unable to use public transportation, such as fixed route buses or trains
  • The medical diagnosis of the Participant which may affect their Non-Emergency Transportation requirements

C.4 Modes of Non-Emergency Transportation and Attendants

The Mode of Transportation requested for a trip must be the most economical mode of transport that will meet the Participant’s needs.

HFS Category of Service (COS) – Mode of Transportation

COS 51. Non-Emergency Ambulance

Transportation of a patient whose medical condition requires transfer by stretcher and medical supervision. The patient’s condition may also require medical equipment or the administration of drugs or oxygen, etc.

BLS (Basic Life Support)
For Participants who are unable to sit in a wheelchair, in need of a stretcher, in need of oxygen during transport, or specific isolation precautions.

ALS (Advanced Life Support)
For Participants in need of life sustaining equipment, or radio or telephone contact with a physician or hospital. These ambulances have equipment to provide appropriate drugs, intravenous therapy, airway intubations, suctioning, and cardiac defibrillation.

COS 52. Medicar Transportation

Transportation of patient whose medical condition requires the use of a hydraulic or electric lift or ramp, wheelchair lockdowns, or transportation by stretcher when the patient’s condition does not require medical supervision, medical equipment, the administration of drugs or oxygen, etc.

COS 53. Taxi or Livery Service

OR

COS 54. Service Car

Transportation by passenger vehicle for Participants who can be transported safely in a regular car.

COS 55. Private Auto

Transportation by a privately-owned passenger vehicle for patients who can be transported safely in a regular car. This transportation provider must also be enrolled with HFS.

COS 56. Other Transportation

For Participants in need of exceptional modes of transport (or Exceptional Modes outside Illinois)

Amtrak, Fixed Route

Public Transportation with an advertised route and schedule (for example, non-commercial buses, commuter trains, subway trains & elevated trains).

Also used for Chicagoland Pace transportation for Participants who have applied and been approved for this paratransit service by the Regional

Transportation Authority. (Note: First Transit identifies this mode of transportation internally as COS 100)

 Attendants

When medically necessary, a person can be approved to accompany Participants in service cars, taxis, and medicars.

There are two types of attendants:

Non-Employee Attendant
A friend, family member, or other individual who accompanies the Participant when there is a medical need.

Employee Attendant
A person other than the driver, who is employed by the NET Provider and accompanies and/or provides assistance to the Participant when there is a medical need.

Non-Employee attendants may be approved to:

  • Travel with a Participant to assist
    • Participate in the Participant’s treatment when medically necessary
    • Learn to care for the Participant after he or she gets out of hospital
  • Translate for the Participant
  • Travel with a Participant to a medical provider, such as a parent going with a young child

Employee attendants may be approved to:

  • Assist a Participant who is not able to walk to appointment
  • Help a Participant with a mental impairment check in for their appointment
  • Carry a Participant in a wheelchair down a number of stairs

Note: First Transit’s Certificate of Transportation Services (CTS) or an equivalent doctor’s statement may be requested to support a category of service and/or attendants.

C.5 NET Providers

First Transit allows the Participant to choose their preferred NET Provider, excluding Exceptional Modes of Transport (EMOTs) and Negotiated Rate Requests.

A Participant may also need to find a different NET Provider if the preferred provider:

  • Is not currently in good standing with HFS
  • Does not provide the Mode of Transportation (Category of Service (COS)) the Participant needs
  • Does not provide service in the Participant’s area

When necessary, First Transit will provide the Participant or their representative with three randomly selected NET Providers to contact for their Non-Emergency Transportation needs.

We ask Providers to contact First Transit if a NET Provider’s contact information has changed or if they no longer provide Non-Emergency Transportation services for NETSPAP.

If no NET Providers are available in the area

First Transit will offer a Participant three NET Providers to contact at a time. Occasionally however, and particularly in remote areas, there may be no NET Providers available to assist them or no more than the ones they have already tried.

In these cases, First Transit will not deny their medical services but may be unable to assist them with their Non-Emergency Transportation request at the time.

If the Participant has a friend or family member who can transport them to their medical appointments, they may be able to enroll as a Private Auto provider. They can contact the Provider Participation Unit at (217) 782-0538 for more information.

C.6 Closest Appropriate Provider

Participants must be transported to the closest appropriate medical provider. To ensure this, First Transit validates a referral for trips above 25 miles in an urban area, 50 miles in a rural area, all trips above 100 miles, and negotiated rate requests. Please submit these requests at least 7 business days in advance.

Participants may have to be transported out-of-state to receive treatment by the closest appropriate provider. This is acceptable as long as the Participant resides in Illinois.

A provider may not be “appropriate” if they are not accepting new or any Medicaid patients.

C.7 Covered vs. Non-Covered Services for Non-Emergency Transportation

In order to be approved for Non-Emergency Transportation services, the Participant must be transported to an appointment where they will receive a covered medical service. A covered medical service is a Medicaid Eligible Medical Service (MEMS).

Examples of Covered and non-covered services are:

Covered Services

  • Chemotherapy
  • Radiation
  • Wellness exam, or annual physical exam
  • Glaucoma, Cataracts
  • X-Rays, MRI, CAT scan, or other diagnostic testing
  • Blood test
  • Hospital admit or discharge
  • Sleep study
  • Outpatient surgery
  • IV infusion
  • Birth control
  • Prenatal care
  • Gastrointestinal problems

Covered Services with Limitations

Emergency room (ER) transports Only approvable if the Participant was referred to the ER by a physician. The referral must be validated before the request can be approved. You will need to provide First Transit with the name and phone number of the referring physician.
Prosthetic device fitting The Participant must be seeing a licensed, certified, health professional; this must be validated by First Transit before the request can be approved.
Prosthetic device pick-up The Participant must be seeing a licensed, certified, health professional and the professional must be performing an adjustment during
the visit; this needs to be validated by First Transit before the request can be approved.
Diabetic teaching; dietician or nutritionist visit Each is allowed once per Participant per lifetime.
Flu shots/vaccinations Must be given by a physician or at a medical facility (not a pharmacy or grocery store) and the Participant must be either a) under 21 years old, b) 22 to 64 years old – only if there is an underlying medical condition which the medical provider believes places the Participant at risk, or c) 65 years old or older
WIC -(Supplemental Program for Women, Infants, & Children) The Participant must be receiving a covered service such as a well child checkup (not just picking up supplies, signing up for benefits, or picking up coupons).
Abortion services Adjudicated on a case-by-case basis.
LTC admit or discharge The Participant cannot be transported out of personal or family choice or convenience. The Request will be evaluated on a case-by-case basis.
Hospital to hospital transports Must be one-way and the Participant must be receiving a Higher Level of Care, that is, inpatient services not available at the originating hospital. Hospital to hospital transports via non-emergency ambulance do not require prior authorization from First Transit. NET Providers may bill HFS directly.
Wheelchair fitting The Participant must be seeing a licensed, certified, health professional; this needs to be validated by First Transit before the
request can be approved.
Wheelchair pickup Approvable ONLY if the wheelchair cannot be delivered and if the Participant is receiving instructions; this must be validated by First
Transit before the request can be approved.
Eye glass fitting and pickup Must be getting an exam or be fitted at time of pickup. For Participants 21 years of age or older the coverage is limited to once every two years.
Group Behavioral Health Services Limited to 2 round trips per week. Not covered for residents 21 years or older residing at a long term care facility.
Tobacco Cessation Counseling Services Covered for:

  • Pregnant and up to 60-day Post-Partum Women age 21 and over for up to a maximum of three quit attempts per calendar year, with up to four individual face-to-face counseling sessions per quit attempt.
  • Children through age 20 with no restrictions.

Non-Covered Services

(Please note, this is not a full list) 

  • Massage therapy
  • Prescription pickup
  • Social Security / SSI medical evaluation
  • Wheelchair repair
  • Smoking cessation for non pregnant women and Participants 21 and older
  • Day care (child or adult)
  • Acupuncture
  • Flu shots or vaccinations at local pharmacies
  • Methadone pickup or treatment
  • Transportation for Emergency services is not covered under NETSPAP. Refer to the handbook for Transportation Services T-200 for emergency transportation procedures.
  • One-way hospital to hospital Transports NOT receiving a Higher Level of Care at the destination hospital
  • Round-trip hospital to hospital transports; the transportation provider must seek payment from the inpatient hospital.
  • ‘No Show’ trips (patient was not transported or was transported but not seen by the medical doctor)
  • Transportation for a Participant who has been declared deceased
  • Medical transportation provided for patients who reside in state-operated facilities; the transportation provider must seek payment from the state-operated facility
  • Artificial insemination
  • Medical or surgical transsexual treatment services
  • Preparation of routine records, forms and reports
  • Services provided only, or primarily, for the convenience of patients or their families
  • Equipment pickup, such as walkers, crutches, bed pans, sick room supplies, etc
  • Pick up for filling prescriptions or any other pharmacy-related item
  • Experimental procedures
  • Infertility/sterility diagnostic or therapeutic proceduresE
  • Early intervention services
  • Sheltered workshops
  • Social rehabilitation programs
  • Day training programs
  • Cosmetic medical treatments
  • Gym
  • Group therapy for Participants 21 years of age or older who reside in a long term care facility

D. Submitting a Non-Emergency Transportation Request

Certain requests can be submitted via phone. Others must be submitted via fax, mail or through PassPORT. If First Transit approves the request: The NET Provider and the Participant must coordinate the pick-up and drop-off times. The NET Provider will need to obtain the Request Tracking Number (RTN) prior to transporting the Participant. If First Transit denies the request:

  • HFS will not pay for the transport
  • The NET Provider should not transport the Participant
  • Alternate transportation must be arranged for the Participant
  • In most instances, a denied request can be resubmitted with additional or updated information for reconsideration

D.1 Information Needed to Book a Routine Request

  1. The Recipient ID Number (RIN) of the Participant
  2. The full name of the Participant
  3. First Assessment information, such as
    • How was the Participant transported in the past?
    • What is the reason the Participant is unable to use this (these) method(s) for this or other future appointments?
    • What is the reason, medical or otherwise, the Participant is unable to use public transportation, such as fixed route buses or trains?
    • The medical diagnosis of the Participant that may affect their Non-Emergency Transportation requirements?
  4. Your full name, title, relationship to the Participant or company, and contact phone number
  5. The pickup address and contact phone number there
  6. The destination address and best phone number to validate the appointment
  7. The name of the doctor and/or medical facility
  8. The medical reason for the appointment on the date of service
  9. Information to assess the category of service:
    • Is the Participant able to walk from the door to the vehicle with little or no assistance?
    • Does the Participant use a wheelchair, cane, walker, or other device?
    • If the Participant uses a wheelchair, is a transferable wheelchair or is the Participant wheelchair bound?
    • Is the Participant able to step into a regular car or do they need a lift?
    • Does the Participant need to travel with someone to this appointment? If so, how will this person assist the Participant?
  10. The name and phone number of the NET Provider
  11. The name and phone number of the referring physician if traveling to the ER, to physical therapy, aqua therapy, speech therapy, occupational therapy, group therapy, over 25 miles in an urban area, over 50 in a rural area, or over 100 miles.

D.2 Types of Requests

One-way, Round Trip, Three Legged Trips

Admits and Discharges are considered one-way trips. Most trips, such as all outpatient services, are round trip. A three-legged trip can be requested when a Participant has to travel to two appointments at different locations on the same day.

One-Way Trip example
HOSPITAL > HOME

Round Trip example
HOME > HOSPITAL
HOSPITAL > HOME

Three-Way OR Three Legged Trip example
HOME > HOSPITAL
HOSPITAL > MEDICAL CENTER
MEDICAL CENTER > HOME

Recurring Trips

If 2 or 3 trips are booked on the same call, going to the same facility, and for the same reason, they will normally be booked together as a recurring trip (with the exceptions below). The NET Provider can use the same RTN to process payment for both.

Standing Prior Authorizations (SPA)

A Standing Prior Authorization (SPA) is required when a Participant is traveling:

  • 2 or more times for Group Therapy, Physical Therapy, Aqua Therapy, Occupational Therapy, and/or Speech therapy

Or

  • 4 or more times for any other medical reason

Standing Prior Authorizations cannot be requested by phone. They must be submitted by fax, mail or through PassPORT.

The most common SPAs are:

  • Aqua Therapy
  • Behavioral Health Services
  • Chemotherapy
  • Dialysis
  • Occupational Therapy
  • Physical Therapy
  • Radiation Therapy
  • Speech Therapy

Chemotherapy and radiation SPAs can be approved 30 trips at a time, Dialysis SPAs are approved up to 6 months at a time and no SPA can be over 6 months.

Standing Prior Authorization Overrides (SPAO)

SPAs for any other reason require further processing and are called Standing Prior Authorization Overrides (SPAOs).

Some SPAO examples are:

  • Cardiac Rehab – Phase II
  • Coumadin Therapy
  • ECT and EECP
  • High Risk Prenatal
  • IV Infusion
  • Obesity
  • Pulmonary Rehab – Phase II
  • Wound Therapy
  • Pain Management
  • (Any SPA via ambulance)

Changes to SPAs and SPAOs

There are certain changes we can make to a SPA without requesting a new one be submitted:

  • Change to the pickup address
  • Change to the destination address if the medical provider is the same
  • Ending the SPA if the services are no longer needed.

To make any other changes we must receive a new SPA. For example:

  • Adding or removing attendants
  • Changing the Mode of Non-Emergency Transportation or Category of Service (COS)
  • Changing the start date
  • Changing the destination address/facility
  • Changing the number of trips per week
  • Changing the total amount of trips
  • Changing the NET Provider

If the days of the week have changed on a SPA, for example, instead of Monday, Wednesday, Friday the Participant will be transported Tuesday, Thursday, Saturday (same number of trips per week and same total number of trips), the SPA does not need to be changed. The NET Provider may use the same RTN to bill HFS.

D.3 Non-Routine Requests and their Requirements

Routine requests, are approved or denied in the call center and usually take 2 business days for processing. Non-routine requests must be validated and can take 5 business days to process.

Below are samples of non-routine requests and the additional information or documentation that must be provided to First Transit:

Non-Routine Request Additional Information/Documentation
Standing Prior Authorizations (SPAs) Varies
Standing Prior Authorization Overrides (SPAOs) Varies
Any transport by non-emergency ambulance (not a hospital discharge) Certificate of Transportation Services (CTS)
If the trip has taken place, the Run Report is also required.
Any hospital discharge by non-emergency ambulance Illinois Medicaid Medical Certification for Non-Emergency Ambulance (MCA)
Any transport by medicar stretcher Certificate of Transportation Services (CTS)
Any Individual Behavioral Health Services (BHS), such as schizophrenia, bipolar disorder, etc. N/A
First trip/Evaluation
to Physical Therapy, Speech Therapy, Aqua Therapy, or Occupational Therapy
Provide First Transit with the name and phone number to the referring physician and the diagnosis for which the therapy is needed
SPA
for Physical Therapy, Speech Therapy, Aqua Therapy, or Occupational Therapy
SPA, copy of referring physician’s order, treatment plan and goals, and written documentation of the primary and secondary medical diagnoses.
First trip/Evaluation
to Group Behavioral Health Services
Provide First Transit with the name and phone number of the referring physician.
SPA
for Group Behavioral Health Services (limited to 2 round trips in a 7-day period)
SPA and Psychiatric Services Treatment Plan Form (PSTP) for CAP/GAP* Providers  – completed by the Participant’s
referring physician and the direct service provider.* CAP/GAP refers to Child/Adolescent Psychiatric Residency/General Psychiatric Residency
Requests over 25 miles in an urban area, over 50 miles in a rural area, over 100 miles and/or negotiated rate requests Provide First Transit with the name and phone number of the referring physician
Lap Band Surgery Varies
Abortion Varies
Home Peritoneal Dialysis Varies
Long Term Care (LTC) admits, discharges, or transfers Varies
Any request where a validation is deemed necessary by First Transit Varies

“Why isn’t my documentation showing up yet?”

Documents may take 2 business days to be received and entered into our system (plus any applicable processing time).

As an example, if a document was faxed on Monday, it may take until the end of day on Wednesday to show as received. On Thursday, First Transit may be requested to do a fax server search.

SASS Requests

The Screening Assessment and Support Services Program (SASS) is an extensive outpatient program providing behavioral health services to children at risk of psychiatric hospitalization. Any child or youth in a mental health crisis may receive SASS services. A qualified Illinois resident may be approved for Non-Emergency Transportation to a SASS service even if they are not a Medicaid Participant.

SASS Providers perform the screenings and authorize the SASS services. They may provide the service or refer the child to another Provider enrolled with the Agency. SASS providers are responsible for providing coverage to a specific geographic area, referred to as a Local Area Network (LAN). Medical Providers should provide First Transit with their LAN.

D.4 Billing Codes

The below codes are used by the NET Provider to bill HFS. When submitting a request through PassPORT, users can select most, if not all, of these codes.

Origin and Destination Codes

– RESIDENCE

  • The Participant’s residence or home
  • A long term care or shelter care facility
  • The residence of the parent, sibling or child that the Participant will be staying with while ill. For example, dialysis or chemotherapy patients may return to a relative’s home because they know they will be too weak to return to their own home
  • Schools, jobs, or any facility that is not a medical facility

D – MEDICAL SERVICE

  • General medical appointments at a clinic with no specific doctor
  • Appointments for medical tests, x-rays, or lab work not performed at a hospital
  • Dialysis, chemotherapy, physical therapy, radiation, or BHS which does not take place at a hospital and no specific physician is seen

P – PHYSICIAN

  • Appointments with a specific doctor at his or her office, whether that office is in a clinic, hospital or private practice

H – HOSPITAL

  • Inpatient treatments
  • Outpatient treatments
  • Lab work, i.e., x-rays, MRI, CAT scans at a hospital
  • Dialysis, chemotherapy, physical therapy, radiation, or BHS taking place at a hospital

First Transit cannot book a trip with “R” to “R” Codes; for LTC Discharges, Transfers, or Admits, use “D” for the facility.

Procedure Codes (P-Codes)

Procedure Codes classify the mileage, attendants, equipment, and categories of service used on trips.

Base Rate:

A0090 – Private Auto

A0120 – Service Car

A0100 – Taxi

A0130 – Medicar

A0426 – ALS Ambulance

A0428 – BLS Ambulance

T2003 – Negotiated Rate

Mileage:

A0425 – Only used on Service Cars, Taxis, Medicars, ALS Ambulances, and BLS Ambulances

Attendants:

T200N – Non-Employee Attendant (only used on Service Cars, Taxis, and Medicars)

T200E – Employee Attendant (only used on Service Cars, Taxis, and Medicars)

Equipment:

A0422 – Oxygen (only used in an Ambulance)

T2005 – Stretcher (only used in a Medicar)

Multiple Participants traveling to the same location

When multiple Participants are traveling to their appointment together only one mileage P-code is used.

When multiple Participants are going to their appointment together, with a different Mode of Non-Emergency Transportation, or Category of Service (COS), each Participant will have their corresponding COS base rate.

E. Forms

First Transit’s forms are available on www.netspap.com. Contact the First Transit Provider line for paper forms to be faxed or mailed to your location or for details on how to properly complete each form.

NETSPAP Single Trip Form

What is it used for?
To submit by fax or mail single trip Non-Emergency Transportation requests, other than a hospital discharge by ambulance.

Who can submit it?
Any HIPAA-authorized representative of the Participant.

NETSPAP Standing Prior Authorization Form (SPA)

What is it used for?
To submit by fax or mail all Standing Prior Authorization (SPA) and Standing Prior Authorization Override (SPAO) requests.

Who can submit it?
Any HIPAA-authorized representative of the Participant

Psychiatric Services Treatment Plan (PSTP) Form for CAP/GAP Providers

What is it used for?
Must be submitted with a SPA for recurring Group Therapy (BHS) Non-Emergency Transportation requests.

Who can submit it?
Section two must be completed by the referring physician. Section 3 must be completed by the Direct Service Provider.

Certificate of Transportation Services (CTS)

What is it used for?
To support a higher level of Non-Emergency Transportation service (or COS) or a request for an upgrade, for all Non-Emergency Transportation requests by medical stretcher, and for all Non-Emergency Transportation requests by non-emergency ambulance (other than a hospital discharge).

Who can submit it?
A licensed, medical professional:

  • Resistered Nurse (RN)
  • Licensed Practical Nurse (LPN)
  • Medical Doctor (MD)

Illinois Medicaid Medical Certification for Non-Emergency Ambulance (MCA)

What is it used for?
To request a hospital discharge by ambulance.

Who can submit it?

  • Physician (Medical Doctor (MD)
  • Doctor of Osteopathic Medicine (DO)
  • Physician Assistant (PA)
  • Advanced Practice Nurse (APN)
  • A designee of the physician, such as a Registered Nurse (RN), Licensed Clinical Social Worker (LCSW), Nurse Practioner (NP) or Discharge Planner

If a designee completes the form, the name and phone number of the physician consulted for the request, must be also be provided.

E.1 What Form Should I Use? A Quick Reference Guide

Hospital Discharges via Ambulance How to Submit the Request to First Transit: The NET Provider must submit the trip request thru PassPORTOther Instructions:

  • The Medical Certification for NonEmergency Ambulance (MCA Form) is available at www.netspap.com.
  • After the transport takes place, Non-Emergency Transportation providers must fax a copy of the MCA Form (with the Request Tracking Number at the top) and the Run Report to First Transit at (630) 873-1450.
  • First Transit cannot process requests for Medicaid Pending Individuals who have not been assigned a Recipient Identification Number. For these individuals, an MCA Form should be completed and handed to the transportation provider at the time of pickup but not submitted to First Transit.
Other transports via Ambulance (other than Hospital Discharge; i.e. admits, round-trips) How to Submit the Request to First Transit:

  • Option 1: Book the request by phone by calling (866) 503-9040 and have the medical provider fax a CTS Form to (630) 873-1450.
  • Option 2: Fax a Single Trip Form and have the medical provider fax a CTS Form to (630) 873-1450.
  • Option 3: Mail a Single Trip Form and have the medical provider mail a CTS Form to 799 W. Roosevelt Rd., Bldg 4, Ste 200, Glen Ellyn, IL 60137.
  • Option 4: Participants, NET Providers, Dialysis Centers, and Long Term Care Facilities may book the trip by PassPORT and the medical provider can fax a CTS Form to (630) 873-1450.

Other Instructions:

  • The Single Trip Form and the Certificate of Transportation Services (CTS Form) are available at www.netspap.com. The CTS Form must have a revised date of 6/20/2013.
  • For Screening Assessment and Support Services (SASS) hospital admits via ambulance, First Transit must receive a Child Severity of Psychiatric Illness (CSPI) Form from the SASS Provider, instead of the CTS Form.
  • After the ambulance transport takes place, Non-Emergency Transportation providers must fax the Run Report to First Transit at (630) 873-1450.
  • To request a Standing Prior Authorization:
    • Option 1: Fax a Standing Prior Authorization (SPA Form) and have the medical provider fax a CTS Form to (630) 873-1450.
    • Option 2: Mail a Standing Prior Authorization (SPA Form) and have the medical provider fax a CTS Form to 799 W. Roosevelt Rd., Bldg 4, Ste 200, Glen Ellyn, IL 60137.
    • Option 3: Participants, NET Providers, Dialysis Centers, and Long Term Care Facilities may book the request by PassPORT and the medical provider can fax a CTS Form to (630) 873-1450.
Transports in a Medicar, Service Car, Taxi, Fixed Route, or Private Auto (including discharges) How to Submit the Request to First Transit:

  • Option 1: Book the request by phone by calling (866) 503-9040.
  • Option 2: Fax a Single Trip Form to (630) 873-1450.
  • Option 3: Mail a Single Trip Form to 799 W. Roosevelt Rd., Bldg 4, Ste 200, Glen Ellyn, IL 60137.
  • Option 4: Participants, NET Providers, Dialysis Centers, and Long Term Care Facilities may book the trip by PassPORT.

Other Instructions:

To request Standing Prior Authorization:

  • Option 1: Fax a Standing Prior Authorization (SPA Form) to (630) 873-1450.
  • Option 2: Mail a Standing Prior Authorization (SPA Form) to 799 W. Roosevelt Rd., Bldg 4, Ste 200, Glen Ellyn, IL 60137.
  • Option 3: Participants, NET Providers, Dialysis Centers, and Long Term Care Facilities may book the request by PassPORT.
  • A CTS Form may be requested by First Transit to support the level of service requested for the Date of Service.

F. Denials

First Transit is required to deny Non-Emergency Transportation requests when they do not meet the criteria for approval. First Transit classifies denials with Denial Reason Codes.

Denial reason codes

Code

Denial Reason

A

The Participant is not eligible for NET (transportation) services on the date of service. The Participant should contact their local DHS office for questions relating to eligibility.

B

The Participant does not have a medical need that requires NET (transportation) services.

C

The medical service for which NET (transportation) services are requested is not a covered medical service.

D

The Participant has access to available NET (transportation).

E

The NET (transportation) requested is covered under another program.

F

The request for post approval was not received timely or did not meet established policy and/or criteria.

G

The trip did not occur because the NET (transportation) provider failed to show.

H

The request failed the validation check with the scheduled medical provider. The medical appointment was not scheduled or was not kept.

I

The request failed the validation check with the scheduled medical provider. The service is not a covered medical service.

J

The request failed the validation check with the Participant and/or the NET (transportation) provider. The Participant was not transported by the NET (transportation) provider approved by First Transit.

K

The request failed the validation check. First Transit cannot confirm there was a medical appointment due to HIPAA or because First Transit was unable to contact the medical provider.

L

The requested trip is not to the closest appropriate medical provider.

M

The NET (transportation) provider requested is not enrolled for the appropriate level of transportation.

N

The NET (transportation) provider requested is not eligible to provide transportation.

O

The NET (transportation) provider chosen by the Participant and approved by First Transit is not available to provide NET transportation services.

P

A PassPORT data entry error occurred.

Q

The Participant, medical provider, or their HIPAA designated representative cancelled the trip.

R

The NET (transportation) provider cancelled the trip.

S

The Participant refuses the appropriate level of NET (transportation).

T

A change to the originally approved NET (transportation) was requested resulting in this trip being denied. If the appointment is still scheduled, the trip may be posted under another Request Tracking Number (RTN).

U

Additional information requested timely by First Transit was not received timely.

V

The trip was not requested timely and the request cannot be accommodated.

W

First Transit data entry error.

X

The trip was approved in error by First Transit.

Y

The trip did not occur because the Participant failed to show and the NET (transportation) provider waited for at least 15 minutes.

Z

First Transit’s review of documentation and/or information obtained does not support the level of service requested.


Denial Letters

Denial letters are sent to the Participant, the NET Provider, and/or the Dialysis Center for some denied requests. These show the code and explanation for the denial.

Participants

  • Denial letters are sent for all Denial Codes, except: H, I, J, K, P, Q, W, and X.
  • Participants are allowed to appeal a First Transit denial. They will find details at the bottom of the denial letter.

NET Providers

  • NET Providers with access to PassPORT receive NO denial letters but receive notification via PassPORT as indicated on the following page.
  • NET Providers with NO access to PassPORT receive denial letters for all Denial Codes.

Dialysis Centers

  • Dialysis centers with access to PassPORT receive no denial letters but receive notification via PassPORT as indicated on the following page.
  • Dialysis centers with no access to PassPORT receive denial letters for Dialysis Standing Prior Authorizations (SPAs)

G. Complaints

A complaint is an oral or written expression of dissatisfaction from a Participant, a Participant’s representative, or a Provider. All complaints received by First Transit are documented and reviewed by management staff and/or members of HFS.

Providers who wish to log a complaint may contact the First Transit Provider line at (866) 503-9040, send an email to complaints@netspap.com, or by fill the electronic form clicking here. Please provide the Customer Service Representative with:

  • Their name and phone number
  • The RIN or RTN of the Participant, if applicable
  • The name of the NET Provider, if applicable
  • Details about the issue or complaint

Complaints regarding Participants who do not act in good faith when using NETSPAP services by being abusive, posing safety risks to others, showing up late or failing to show up for approved trips, etc., will be researched and handled by First Transit.

H. Appeals

PARTICIPANT APPEALS

Participants are allowed to appeal a denial by First Transit by contacting the corresponding phone number located on the bottom of the denial letter within 60 calendar days of the date of the letter. The Bureau of Administrative Hearing’s, Fair Hearing Section, may schedule a hearing for the Participant. A First Transit representative, will provide testimony regarding the Non-Emergency Transportation denial.

GROUND AMBULANCE APPEALS

Level 1 and Process by First Transit, Inc:

Ground Ambulance Service Providers may appeal a denial for an ambulance level transport. To do so, the Ambulance provider must file a written, signed request for appeal within 60 calendar days of the date the decision is received pursuant to 89 III Adm. Code 140.491(j). The date of the decision is available on PassPORT. The ground ambulance provider must submit the appeal request to:

First Transit, Inc

799 W. Roosevelt Road,

Building 4, Suite 200

Glen Ellyn, IL 60137-5908

Attention: Ambulance Appeals Section

Note: First Transit will assign an internal tracking number to the ground ambulance appeal which shall be used to track a timely response.

Pursuit to 89 Ill. Adm. Code 104.205, First Transit performs an informal review of the ground ambulance appeal. The initial step will be to determine if all required information is present, including:

  • a copy of the denial
  • proof of the date the denial was received to support the 60 day time filing limit
  • a brief statement of the issue on appeal
  • documentation supporting the appeal request


Note: Any documentation that was NOT previously submitted to HFS or First Transit prior to the decision rendered in accordance with 89 Ill. Adm. Code 140.491(j) must be designated as not having been previously submitted.

If the appeal did not include all of the required information or the request was not timely, First Transit will issue a letter to the provider, along with the materials submitted, explaining the materials submitted did not meet the required criteria, as well as a checklist of missing forms. Any appeal that was NOT filed timely cannot be resubmitted for review.

If the appeal was timely and included all required information, a First Transit Nurse Manager will conduct an informal review of the request for ground ambulance appeal, including a review of all documentation. First Transit shall, within 60 calendar days of receipt of the appeal, issue the written decision to reverse, modify or affirm the Department’s initial decision. The following action may occur:

a. The ground ambulance service provider may proceed to re-bill HFS after First Transit’s informal review reversed or modified decisions.

b. Vendor/HFS must correct the prior authorization system to allow the ground ambulance claim to pay for reversed or modified decisions.

c. On affirmed decisions: ground ambulance service provider may request a hearing within 10 days of the First Transit informal review notification decision and have a right to a hearing, by filing a written, signed request for a hearing with the Office of General Counsel-Bureau of Administrative Hearing-Vendor Hearings Section and to the Office of Inspector General-Bureau of Administrative Litigation.


Note: any request for a hearing NOT received within the 10 day window noted above, or an appeal later withdrawn, the Department’s decision shall be final and binding administrative determination.


Second Level by Office of General Counsel – Bureau of Administrative Hearing- Vendor Hearings Section and to the Office of Inspector General-Bureau of Administrative Litigation.

The Bureau of Administrative Hearing’s Fair Hearing Section may schedule a hearing for a Ground Ambulance Service Provider and will forward a Notice of Hearing with the date and time to both First Transit and HFS.  A timely filed hearing request shall be heard by the Bureau of Administrative Hearing.

Note:  Documentary evidence submitted for the hearing shall be limited to documents submitted to First Transit’s informal review (level 1 described above) unless good cause is shown otherwise.

If an appeal hearing is conducted, the First Transit Nurse Manager and Call Center Manager may provide sworn testimony.  The Bureau of Administrative Hearing will issue a recommended decision and shall submit it to the Director, HFS, and the Respondent (ambulance provider) or his/her counsel and the Department’s counsel.  Both may file written exceptions with the Director, HFS within 10 days of receipt of the notification.

Both Respondent and the HFS’s counsel may file a written response to the exceptions with the Director, HFS, within 5 days of receipt of the exceptions.

Director, HFS issues a final written administrative decision.  If decision is reversed by the Director, HFS, the ground ambulance provider may bill the HFS for the non-emergency services.  The HFS authorization system will be updated to allow payment of the ground ambulance claim.

Third Level under Administrative Review Law

The final decision is reviewable only by a timely complaint filed under the Administrative Review Law (Ill Rev. Stat. 1989, ch. 1100, par. 3-101 et seq.).  The ground ambulance provider would have to file this complaint.  The HFS shall abide by any decision made by this review and shall act accordingly.

I. Fraud, Waste and Abuse

First Transit works to reduce fraud, waste and abuse by validating many of the received Non-Emergency Transportation requests and screening for any suspicious activity.

When First Transit suspects that a NET Provider, Provider, or Participant is engaging in fraudulent, unethical, or illegal business activities, the activity is to be reported to the Office of Inspector General (OIG) through a formalized process.

The mission of the Office of Inspector General (OIG) is to prevent, detect and eliminate fraud, waste, abuse, misconduct and mismanagement in programs administered by Healthcare and Family Services and the Department of Human Services.

We ask our Providers to contact First Transit at the Provider Line (866) 503-9040 for any activity that could result in fraud, waste or abuse. Providers may also report the issue directly to OIG by visiting https://www.illinois.gov/hfs/oig/Pages/mcoidcomplaints.aspx?FT-QRU-6NKAPDJ7YXZ4W

J. Validations

First Transit is contractually required to pre-validate (confirm trips prior to the transport) and post-validate (confirm trips after transport) a percentage of all trips received. Most validations are selected randomly but First Transit will attempt to validate other appointments at the discretion of our staff.

When validating, First Transit attempts to confirm the Participant a) has a scheduled medical appointment (or kept it) and b) that the appointment is for a covered medical service. Upon validation, First Transit requests the name and title of the individual validating the information.

Pre-Validation

While a Participant is requesting a prior authorization for Non Emergency Transportation, the request may require a pre-validation of the Medical Service. First Transit will contact the Medical Provider to verify that the appointment was made, and, that the service is a Covered Medical Service.  If the validation attempt fails, the trip will be denied for failed validation. The Participant will be provided an opportunity to request the trip again with more information that may be used to validate the Medical appointment, such as a correct phone number of the Medical Provider. If First Transit is able to validate the appointment, the trip request can be rebooked and approved.  If the appointment still cannot be validated, the request may be denied, but the Participant still can call again with additional information.

Post-Validation

First Transit shall contact the Medical Provider to verify that the appointment was made, verify that the service used was a Covered Medical Service for the Participant, and verify that the Participant kept the appointment.  For those cases that fail the validation, the trip may be denied and a report may be sent to the Office of Inspector General for further review.

Medical Provider refusal to validate due to HIPAA

If the medical provider voices a concern about validating an appointment due to HIPAA, First Transit will offer to fax our HIPAA letter from HFS explaining how HFS is a business partner to First Transit and therefore information can be released. If the provider accepts to review the letter, First Transit will place the request on hold for 2 business days for a call back validating the request. For Pre-Validations, if no call back is received within the 2 days or the provider refuses to receive our letter, the Non-Emergency Transportation request will be denied for failed validation.

K. New Programs or Guidelines

Procedures Regarding Hospital Discharges Via Non-Emergency Ambulance

If you received a denial for hospital discharges with dates of service on or after July 1, 2013 because a MCA form was not submitted to First Transit or not completed properly, please follow the following procedures.

  • The ambulance provider should enter the single trip request through PassPORT.
  • The NET provider must fax the completed MCA or PCS Form plus the Run Report to First Transit. For Dates of Service 7/1/13 – 12/31/13 a completed MCA or PCS and Run Report is accepted. However, Dates of Service on or after 1/1/14, a completed MCA and a Run Report will be required for all Hospital Discharges.