Chapter 538 School-Based Health Services Transportation 2019

Demographics Modified Medicaid Number Last Name First Name County School   WVEIS # Diagnosis Code Date of Birth Month/Year Vehicle Type Modified

Two Codes to Choose __T2001 SE – Non-Emergency Medical Transportation – with Bus Aide. T2002 SE – Non-Emergency Medical Transportation – without Bus Aide. (Up to 4 one-way trips per instructional day.) Locations would be school, home, or designated stop (DS). If other than these indicate the specific location. Driver and aide signatures are only verifying the student’s total monthly trips.

Non-Emergency Medical Transportation with Bus Aid Procedure code: T2001SE Service Unit: TRIP Service Limits: Four one-way trips per instructional day Definition: Non-emergency medical transportation with attendant is a service in which a one-way transport of a member by a vehicle other than an ambulance is provided. If more than one member is being transported, each members’ transport to the Medicaid service is billed. Non-emergency transportation with an attendant may only be billed when a Medicaid covered service is billed for the same date of service and the attendant is present during the transport.

Non-Emergency Transportation Procedure code: T2002 SE Service Unit: TRIP Services Limit: Four one-way trips per instructional day Definition: Non-emergency medical transportation is a service in which a one-way transport of a member by a vehicle other than an ambulance is provided. If more than one member is being transported, each member’s transport to the Medicaid service is billable. Non-emergency transportation may only be billed when a Medicaid covered service is billed for the same date of service.

Documentation Date Departure Location Arrival Location Start Time Stop Time  

Documentation Documentation must contain an activity note for each separate transport describing the purpose for the transport, the of vehicle used for the transport, place of departure and arrival, date of service, signature of the providing staff (along with their credentials), and actual time spend providing the service by listing the start-and-stop times.

Signature and Credentials Total Trips Total Billable Trips Total Non-Billable Trips *District staff completes the total billable and non-billable boxes based upon dates the student receives billable services. Driver Signature: Driver Credential: Bus Aide Signature: Bus Aide Credential:

Contact Information Kelley Johnson – Coordinator Office of Special Education kelley.johnson@k12.wv.us 304-558-2696 ext 53539 WVDE Medicaid Website: https://wvde.us/special-education/Medicaid/