DHSS / Behavioral Health P&P Template
STATE OF ALASKA
DEPARTMENT OF HEALTH & SOCIAL SERVICES
SECTION:
NUMBER:
PAGE:
TITLE:
BEHAVIORAL HEALTH
POLICY & PROCEDURE
ATTACHMENTS/FORMS:
The Medical Assistant Transportation Authorization
And Invoice (AK-04)
NONEMERGENCY TRANSPORTATION AND
ACCOMMODATIONS SERVICES REQUIRING
THE DIVISION OF BEHAVIORAL HEALTH
APPROVAL– CHILDREN'S BEHAVIORAL
HEALTH RESIDENTIAL TREATMENT
PROGRAMS
APPROVED:
DATE:
INITIATED: 4/30/12
REVIEWED:
REVISED:
POLICY OWNER: Department of Health and Social
Services
Purpose: The purpose of this policy is to outline procedures to obtain approval from the Division of
Behavioral Health (DBH) staff prior to requesting service authorization for nonemergency transportation
and accommodations for Medical Assistance recipients.
Scope: This policy applies to all participating rural tribal community behavioral health centers identified
in the Bring the Kids Home Tribal Rural Gaps Assessment Follow-Up Project.
Policy: All nonemergency transportation for youth and/or their families to and/or from a residential
treatment center must be approved by DBH staff prior to requesting service authorization for travel and
accommodations.
Definitions:
EPSDT- the early periodic screening, diagnosis, and treatment program under Medical Assistance.
Escort- a person who accompanies a recipient to or from medical care; the purpose of the escort
accompanying a recipient may be the result of medical necessity or may be due to the age or physical or
mental capacity of the recipient; the escort may be medically trained, but medical training is not required;
an escort is not compensated by the department.
Accommodation Services- food and lodging for an eligible recipient, the recipient’s escort, or both, while
the recipient is receiving medical care at a facility away from the area where the recipient resides.
Page 1 of 8
NONEMERGENCY TRANSPORTATION AND ACCOMMODATIONS SERVICES REQUIRING THE
DIVISION OF BEHAVIORAL HEALTH APPROVAL– CHILDREN'S BEHAVIORAL HEALTH
RESIDENTIAL TREATMENT PROGRAMS
References: 7 AAC 120.200, 7 AAC 120.490
DHSS / Behavioral Health P&P Template
Food and Lodging- means meals and sleeping facilities for the recipient, escort, or both, while the
recipient is receiving medical care at a facility away from the place where the recipient regularly resides;
"food and lodging" does not include

meals and sleeping facilities provided by friends or relatives of either the recipient or the escort;
or

accommodations provided in hospitals or nursing homes
Medical Transportation- means transportation for medical purposes to and from any source of medical
care or between medical facilities, food and lodging incidental to such transportation for both recipients
and escorts when needed.
Nonemergency Travel- travel is considered non-emergent if there is no emergency requiring the need to
travel.
Therapeutic Leave of Absences (LOA) - the purpose of an LOA is to facilitate successful transitions from
residential settings to less restrictive or community based behavioral health services upon discharge.
Prior Authorization- approval by the department of a certain type of Medical Assistance-covered service
and the number of units of services before those services are provided. This term may be used
interchangeably with service authorization.
Provider of Transportation- means the owner or operator of a private automobile, municipal bus, intercommunity bus, taxi, scheduled airline, ferry, wheelchair coach, train, chartered aircraft, chartered boat,
or other mode of transportation commonly used to transport a person; and a person who contracts with an
air carrier to provide chartered or scheduled air services.
Recipient- an individual who has been determined eligible for Medical Assistance and who is receiving, is
authorized to receive, or has received a Medical Assistance-covered service from a provider enrolled in
the Medical Assistance program in this state.
Tribal Health Program- means a hospital, clinic, or other type of health care facility or program operated
by
(A) the United States Department of Health and Human Services, Indian Health Service;
(B) an Indian tribe as defined in 25 U.S.C. 450b(e) and 458aaa(b);
(C) a tribal organization as defined in 25 U.S.C. 450b(l); or
(D) an inter-tribal consortium as defined in 25 U.S.C. 458aaa(a)(5) or established by federal law.
Responsibilities: TO BE DEFINED
Page 2 of 8
NONEMERGENCY TRANSPORTATION AND ACCOMMODATIONS SERVICES REQUIRING THE
DIVISION OF BEHAVIORAL HEALTH APPROVAL– CHILDREN'S BEHAVIORAL HEALTH
RESIDENTIAL TREATMENT PROGRAMS
References: 7 AAC 120.200, 7 AAC 120.490
DHSS / Behavioral Health P&P Template
Procedures:
Travel is considered non-emergent if there is no emergency requiring the need to travel. An example of
this would be a recipient traveling for a scheduled appointment. The following guidelines apply to nonemergency transportation services:

Non-emergency medical transportation services must be authorized in advance by Xerox, the
fiscal agent for Alaska medical assistance.

Non-emergency transportation is not authorized for weekends. All medical appointments must be
scheduled during normal working hours of transportation providers and healthcare providers.

Non-emergency ground transportation for medical services is not covered by Alaska medical
assistance when the recipient lives in and receives medical care in the same community.

Non-emergency ground ambulance services if it is warranted by the recipient's medical condition.
The department will pay a provider for only those transportation and accommodation services that are

medically necessary

prior authorized
The department will pay for non-emergency transportation and accommodation services provided without
prior authorization if

a recipient is forced to change travel plans for reasons beyond the recipient's control

the medical service for which the recipient traveled reveals the need for additional services that
requires the recipient to stay longer than previously approved
The department may pay for a service without prior authorization if:

prior authorization was not possible before the service was provided

a claim for payment is being processed after the service was provided based on a determination of
a recipient's retroactive eligibility
The department may approve transportation and accommodations outside the recipient's community of
residence to obtain medically necessary services for the recipient if

those services are not available in the recipient's community

the total cost for Medical Assistance services with transportation and accommodation costs is less
than the cost of the services at a facility within the recipient's community of residence
Page 3 of 8
NONEMERGENCY TRANSPORTATION AND ACCOMMODATIONS SERVICES REQUIRING THE
DIVISION OF BEHAVIORAL HEALTH APPROVAL– CHILDREN'S BEHAVIORAL HEALTH
RESIDENTIAL TREATMENT PROGRAMS
References: 7 AAC 120.200, 7 AAC 120.490
DHSS / Behavioral Health P&P Template

the recipient is an American Indian or Alaska Native who has requested services from a tribal
health program
The department will not pay for

transportation or accommodations that the department determines to be excessive or inappropriate

transportation for a recipient two years of age or younger if the department pays the cost for an
escort to accompany the child, unless the condition of the child prevents the child from riding in
the same seat as the escort;

transportation for a recipient or an authorized escort to travel to a health care provider or Medical
Assistance service provider that is not enrolled as a Medical Assistance provider, unless the
provider is a military or veterans' facility

ground transportation, including travel by automobile, taxi, and bus, for a recipient to travel to a
health care provider within the recipient's community of residence, unless
o
the recipient's medical condition justifies the need for transportation
o
an undue hardship would result from a denial of the transportation
o
the transportation is required as an EPSDT service

separate accommodations for a recipient and escort, unless the circumstances warrant separate
accommodations

return transportation if the recipient discharges from a facility Against Medical Advice (AMA)
Accommodations
The department will pay for accommodation services. Accommodation services are food and lodging for
an eligible recipient, the recipient’s escort, or both, while the recipient is receiving medical care at a
facility away from the area where the recipient resides. Meals and lodging are not authorized for children
two years of age and under.
The department will not pay for nonessential services as part of accommodation services. Nonessential
services include
o
alcoholic beverages
o
pay television
o
long distance telephone calls
Page 4 of 8
NONEMERGENCY TRANSPORTATION AND ACCOMMODATIONS SERVICES REQUIRING THE
DIVISION OF BEHAVIORAL HEALTH APPROVAL– CHILDREN'S BEHAVIORAL HEALTH
RESIDENTIAL TREATMENT PROGRAMS
References: 7 AAC 120.200, 7 AAC 120.490
DHSS / Behavioral Health P&P Template
o
tips
o
laundry
o
dry cleaning
o
o
meals or lodging for a relative or guest who is not serving as an authorized escort
accommodations for a recipient or escort if appropriate lodging is available to the
recipient or authorized escort at no expense
Escorts
The department will approve an authorized escort to accompany a recipient during travel authorized by
the department for medical treatment if

The recipient is 17 years of age or younger.

The recipient is 18 years of age or older and the escort is medically necessary for the recipient.

Additional escorts may be requested based on medical necessity and supporting clinical
documentation.

Transportation for recipients under the age of two years is not covered. However, travel is
covered for an escort so that the child may sit on the escorts lap. The child then escort must also
share meals.

Please note that escorts are not for interpretation services and/or social reasons.
All transportation and accommodation services for an escort must be approved by the department before
transportation and accommodation services are provided. The recipient's health care provider must
request authorization for an escort at the same time transportation and accommodation services are
requested for the recipient.
Prior/Service Authorization
The recipient's behavioral health care provider requests prior/service authorization for transportation and
accommodations. Transportation and accommodations must be requested at the same time. To request
prior authorization (PA) the provider must:

Contact Xerox at (800) 770-5650 or (907) 644-6800.

When calling, make sure all essential information is at hand, this includes:
Page 5 of 8
NONEMERGENCY TRANSPORTATION AND ACCOMMODATIONS SERVICES REQUIRING THE
DIVISION OF BEHAVIORAL HEALTH APPROVAL– CHILDREN'S BEHAVIORAL HEALTH
RESIDENTIAL TREATMENT PROGRAMS
References: 7 AAC 120.200, 7 AAC 120.490
DHSS / Behavioral Health P&P Template
o
the clinic, village or facility for whom you work
o
your phone number
o
the name of the recipient and ID number
o
the date of birth
o
the eligibility code
o
the appointment date and time
o
the diagnosis (this does not have to be an ICD-9, code but maybe a description of the
illness or issue)
o
the procedure being done
o
the recipient's trip origin and destination
o
the referring and receiving doctors
o
if requesting multiple visits, clinical justification
o
if requesting travel outside of Alaska, clinical justification
o
if an escort is needed (include justification for escort and escort name)
o
if a taxi or accommodations are needed

When changing or canceling a single or multiple prior authorizations, please provide the prior
authorization (PA) number and the reason for the change or reschedule.

When calling with more than one traveler change, please inform the PA representative at the
beginning of the call.

When requesting an escort, have the escorts name and relationship to the recipient. Be prepared to
answer what the medical necessity is and why the recipient is unable to travel alone. Please note
that escorts are not for interpretation services and/or social reasons.

Be sure to inform the escort of their roles/duties. Their role is an escort has been approved for
reasons of medical necessity and requires their assistance from the beginning to the end of the
travel, unless the recipient is admitted into a hospital.

Ensure that the recipient in their escort understand that vouchers are to be used for their travel
pertaining to the medical appointment only. If the medical appointment is canceled or
rescheduled for any reason the escort is forbidden to use air lodging mailer taxi vouchers for
personal use.
Page 6 of 8
NONEMERGENCY TRANSPORTATION AND ACCOMMODATIONS SERVICES REQUIRING THE
DIVISION OF BEHAVIORAL HEALTH APPROVAL– CHILDREN'S BEHAVIORAL HEALTH
RESIDENTIAL TREATMENT PROGRAMS
References: 7 AAC 120.200, 7 AAC 120.490
DHSS / Behavioral Health P&P Template

Be sure to inform the recipient and their escort that vouchers cannot be replaced if they are lost.

Recipients must have a physician’s referral for travel.
Please note that the Division of Healthcare Services, fiscal agent Xerox, is in the process of updating the
travel voucher form. The current form, “The Medical Assistant Transportation Authorization and Invoice
(AK-04)”, will continue to be honored.
Division of Behavioral Health (DBH) Approval for Children’s Residential Programs
Transportation and accommodations for youth and/or their families requires approval from DBH
Medicaid and Quality staff before initiating the prior authorization process. All travel must be planned
and requested at least 14 days in advance of travel and documented as medically necessary in the
recipient’s medical file.
DBH Staff may be contacted at the Anchorage Regional Office 907-269-3600 or 800-770-3930. Please
have ready the youth’s treatment plan and other supporting clinical information.
I.
Onsite Family Therapy- One family member may be approved for travel and accommodations to
the community in which the recipient resides in the residential setting. Additional family
members may be eligible for travel depending on clinical justification. Onsite Family Therapy
travel may be approved every 90 days unless clinically contraindicated. The duration of the visit
period must be 5 days or less. The clinical record must include a treatment plan that documents:
a. Family Psychotherapy at least once during requested visit period
b. Family interventions planned on a daily basis during requested visit period
II.
Therapeutic Leave of Absences (LOA)- May include home passes for the recipient at the family
home, foster home, or other less restrictive residential or outpatient treatment options in
preparation for discharge from current setting. LOAs may also include overnight leave with
family in conjunction with onsite Family Therapy. Clinical documentation providing support for
LOAs must include:
a. A crisis plan that identifies behavioral health service provider(s) that will support and
facilitate treatment should a crisis occur (contact person name, credentials, phone
number)
b. Goals and objectives of the LOA including how the LOA will assist the youth and family
in achieving treatment goals and objectives
c. Documentation of previous LOAs
d. Departure and return dates
Page 7 of 8
NONEMERGENCY TRANSPORTATION AND ACCOMMODATIONS SERVICES REQUIRING THE
DIVISION OF BEHAVIORAL HEALTH APPROVAL– CHILDREN'S BEHAVIORAL HEALTH
RESIDENTIAL TREATMENT PROGRAMS
References: 7 AAC 120.200, 7 AAC 120.490
DHSS / Behavioral Health P&P Template
e. Appointments with the identified behavioral health community based provider(s)
f.
Appointment with the youth’s school is highly recommended
Page 8 of 8
NONEMERGENCY TRANSPORTATION AND ACCOMMODATIONS SERVICES REQUIRING THE
DIVISION OF BEHAVIORAL HEALTH APPROVAL– CHILDREN'S BEHAVIORAL HEALTH
RESIDENTIAL TREATMENT PROGRAMS
References: 7 AAC 120.200, 7 AAC 120.490