Library: Policy

317:30-5-327.1. SoonerRide NEMT coverage and exclusions

Revised 9-1-21

(a) SoonerRide NEMT coverage. SoonerRide NEMT is available for SoonerCare compensable services under the following conditions:

(1) Nearest appropriate facility.

(A) Transportation is to the nearest appropriate facility or medical provider that is capable of providing the necessary services.

(B) SoonerRide NEMT services to a more distant hospital, clinic, practitioner or physicians' office solely to avail a member of the service of a specific physician or physician assistant does not make the institution in which the physician has staff privileges the nearest institution with appropriate facilities.

(i) The member's condition requires a higher level of care or specialized services available at a more distant facility; or

(ii) There are no beds or providers available. Medical records must be properly documented in this circumstance.

(2) Radius. Primary care and specialty SoonerCare compensable services should be available within forty-five (45) miles of the member's residence. The Oklahoma Health Care Authority (OHCA) has the final authority to approve or deny travel greater than forty-five (45) miles to access these services.

(A) Residency change. Should a member change residence then care will be established within forty-five (45) miles of the new residence.

(B) American Indians/Alaska Natives (AI/AN). AI/AN members that are seeking services at a Tribal or Indian Health Services (I.H.S.) facility may be transported to any Tribal or I.H.S. facility equipped for their medical needs. All trips to out-of-state facilities require prior authorization and approval.

(3) Services requiring prior authorization.

(A) Travel that exceeds the forty-five (45) mile radius, as mentioned in Oklahoma Administrative Code (OAC) 317:30-5-327.1 (a) (2), must be authorized and approved; and

(B) Out-of-state travel for prior authorized out-of-state medically necessary services, must also be authorized and approved.

(b) Discharge coverage. SoonerRide NEMT is available if a member is being discharged from a facility to their home. The facility is responsible for scheduling the transportation. SoonerRide NEMT is only responsible for transporting the member.

(1) Personal belongings and/or durable medical equipment (with the exception of portable oxygen or a wheelchair that is medically necessary for transportation) will not be transported through SoonerRide NEMT.

(2) Wheelchairs must be provided by the medical escort/member. This item is not provided by the SoonerRide NEMT transport.

(c) Medical escorts/service animals/additional passengers. In instances where there is documented medical necessity, a medical escort or service animal may accompany the member.

(1) Medical escort. A medical escort is not eligible for direct compensation by the SoonerRide NEMT broker or SoonerCare.

(2) Service animal. The SoonerRide NEMT broker may request additional information regarding the service animal, including but not limited to, if the animal is required because of a disability and what work or task the animal has been trained to perform.

(3) Removal of the service animal. The SoonerRide NEMT broker may ask for the service animal to be removed if it is not under the control of the handler or if it is not housebroken/trained. Additionally, the SoonerRide NEMT broker and the OHCA are not responsible for the care and supervision of the service animal.

(4) Additional passengers. SoonerRide NEMT is not required to transport any additional individuals other than the one (1) approved individual providing the escort services.

(A) Additional passengers request. In the event that additional individuals request transportation, it is the responsibility of the member to contact the transportation provider directly to request allotment of additional passengers. The SoonerRide NEMT broker will not facilitate this request.

(B) Exceptions for urgent appointments. Exceptions may be granted if the medical appointment is urgent in nature and meets the criteria outlined in Oklahoma Administrative Code (OAC) 317:30-5-327.1 (d) (1)- (3).

(d) Urgent appointments and additional passengers. An urgent appointment can be for either a sick child or sick parent/guardian. The member must make the request for additional child passengers when making the trip reservation. A maximum of three (3) children can ride with the parent/guardian. The total number of passengers, including the driver, cannot exceed more than five (5) persons for any vehicle. In addition, the following conditions must be met:

(1) Urgent medical appointment. The medical appointment must be urgent (for a sick child or sick parent) as determined by the member's doctor. The SoonerRide NEMT broker will confirm that the medical appointment is urgent with the member's doctor;

(2) Children. All children must be the member's by birth, marriage, legal adoption, foster child, or legal guardianship. Further, the additional children passengers must be younger than thirteen (13) years of age. Exception will be granted if a child has complex, medical, intellectual, or physical disabilities that requires constant care and supervision; and

(3) Car seats for children. Each child must have his or her own car seat, provided by the member, if required by Oklahoma state law.

(e) Forms of transportation. SoonerRide NEMT can include one (1) of the following forms of transportation:

(1) Authorization for transportation by private vehicle or bus. Transportation by private vehicle or bus is administered through the broker when it is necessary for an eligible member to receive medical services.

(2) Authorization for transportation by taxi. Taxi service may be authorized at the discretion of the broker.

(3) Transportation by ambulance. Transportation by ambulance is only provided for non-emergency scheduled stretcher service.

(4) Transportation by airplane. When an individual's medical condition is such that transportation out-of-state by a commercial airline is required, approval for airfare must be secured by telephoning the OHCA who will make the necessary flight arrangements.

(f) Exclusions for SoonerRide NEMT. SoonerRide NEMT coverage excludes the following:

(1) Emergency services. Transportation of members to access emergency services;

(2) Ambulance. Transportation of members by ambulance for any reason, except for non-emergency scheduled stretcher service per OAC 317:30-5-327.1 (e) (3);

(3) Non-compensable services. Transportation of members to services that are not covered by SoonerCare; and

(4) Non-medically necessary services. Transportation of members to services that are not medically necessary.