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.