Transportation Rationale (continued)
By initialing to the right of each* of the statements below, the CCE/NPN Clinical Director/Designee attests that there is
documentation in the member’s record of the member’s risk of a medical emergency, the need for an ambulette or
ambulance, and the following statements are applicable:
The member has no other means of transportation available through public transportation, city or state public service
assistance agencies, or known acquaintances; and
The vehicle providing services to the member is traveling directly to or from one of the listed locations:
Medical Necessity Attestation
By initialing at least one* of the statements below, the CCE/NPN Clinical Director/Designee attests that there is
documentation in the member’s record of the member’s risk of a medical emergency, the need for an ambulette or
ambulance and the non-emergency medical transportation is determined to be medically necessary because at least one of
the following criteria is established:
The member is wheelchair bound or has a disabling physical condition that requires the use of a walker or crutches and
is unable to use a taxi, livery service, bus, train, or private vehicle (e.g., due to the use of a non-collapsible wheelchair or
otherwise requiring a specially configured vehicle); and/or
The member requires radiation therapy, chemotherapy, or dialysis treatments that result in a disabling physical
condition, making the member unable to access transportation without personal assistance provided by non-emergency
medical transportation; and/or
The member has a severe debilitating weakness or a disabling physical condition, other than the one described above,
requiring the personal assistance provided by non-emergency medical transportation; and the ordering provider certifies
and provides in narrative that the member cannot be transported by taxi, livery service, bus, or private vehicle as a
result; and/or
The member is mentally disoriented as a result of medical treatment, or has a mental impairment or a disabling mental
condition, and requires the personal assistance of non-emergency medical transportation; and the ordering provider
certifies and provides in narrative that the member cannot be transported by a taxi, livery service, bus, or private vehicle
as a result (e.g., member is disoriented to person/place/time; acute severity hallucination; delusions/inappropriate in
public situations; threat/suicidal/homicidal with a plan; acute psychotic symptomatic manic episode; chemical
dependency – acute withdrawal or acute intoxication); and/or
The member has a functional orthopedic impairment precluding unassisted ambulation (bilateral or unilateral amputee,
lower extremities; cast on lower extremity or half body; fracture of pelvis, hip, femur or leg; severe arthritis of locomotor
joint); and/or
The member has a neuromuscular impairment precluding unassisted ambulation (spinal injury); and/or
The member has suffered a cerebrovascular accident with resultant hemiplegia or hemiparesis (stroke); and/or
The member has peripheral vascular disease precluding unassisted ambulation (severe claudication; foot ulceration);
and/or
The member has severe respiratory disease (emphysema; chronic obstructive pulmonary disease; and chronic
bronchitis) or cardiac disease necessitating physical assistance on stairs; and/or
The member has some other physically disabling health condition or treatment preventing the member from being
transported by a taxi, livery service, bus, or private vehicle (justify in the space below):
*Note: All of the above statements must be true in order for the member to meet the Non-Emergency Medical Transportation MCD criteria.
*Note: One of the above statements must be true in order for the member to meet the Non-Emergency Medical Transportation MCD criteria.
