2022-10 CalOptima Health-Referral Request Transportation Services And Physician Certification Statem-2025

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CalOptima provides mileage reimbursement when transportation is in a private vehicle arranged by the beneficiary and not through a transportation broker, bus passes, taxi vouchers or train tickets. CalOptima allows the lowest cost NMT type that meets your medical needs.
Paramedics determined medical necessity of patient transport based on the following five criteria: 1) need for out-of-hospital intervention; 2) need for expedient transport; 3) potential for self-harm; 4) severe pain; or 5) other.
Medical Reasonableness for Ambulance Transport Some examples of medical necessity for emergency ambulance transport are: Injury resulting from an accident or illness with acute symptoms like hemorrhage, shock, chest pain, respiratory distress, etc.
The physician certification statement (PCS) is a statement signed and dated by the beneficiarys attending physician which certifies that the medical necessity provisions of paragraph (e)(1) of eCFR: 42 CFR 410.40 Coverage of ambulance services are met.
Use HCPCS code A0427 (ambulance service, advanced life support, emergency transport, level 1 [ALS1-emergency]) or A0429 (ambulance service, basic life support, emergency transport [BLS-emergency]) when billing for response to an emergency (911) call.
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