DHCS Regulatory Notice – APL 22-00826-XXX Comment/Feedback Requested
REGULATORY NOTICE–01–005
COMMENTS/FEEDBACK REQUESTED
May 28, 2026
Dear CA Ambulance Provider Members,
Our office has been engaged in regulatory advocacy efforts on a number of issues affecting ambulance providers. First, it was brought to our attention that certain MCPs or their transportation brokers were not adhering to point of origin/destination authorization exemptions as clarified by DHCS. Second, our provider members and representative organizations brought to our attention issues regarding unduly restrictive requirements surrounding PCS Forms.
In response, our office has engaged in active efforts to have the DHCS clarify and rectify these issues that are impacting our individual providers as well as the overall system that all ambulance providers participate in.
At this time, the DHCS has issued an amendment of APL 22-008 that addresses a number of issues, including both of the concerns above. We have summarized the changes for you in the table below.
We ask that you carefully review this notice, the amended APL with track changes, and provide any comments or feedback prior to the close of the comment period by COB June 9, 2026. Please review the instructions on the APL Comment Log Feedback (excel sheet) and utilize that form to document comments/feedback, so that we can timely compile them for review and transmission to the DHCS. If your organization has any stories or experiences which support, supplement, or document a proposal/comment/feedback, we suggest that you include it to strengthen your position.
| APL 22-008 | APL 26-XXX (Supersedes APL 22-008) |
| Prior Authorization: NEMT services are subject to prior authorization. The member must have an approved PCS form authorizing NEMT by the provider. | Prior Authorization: NEMT services require a prescription, and each ride is subject to Prior Authorization to ensure the requested ride is for an MCP Covered Service or pharmacy service, unless it is for an NEMT service exempt from Prior Authorization. The Member must have a PCS form prescribing NEMT by an appropriate Provider before Prior Authorization can be granted for NEMT. |
| Prior Authorization Exception: A member or provider is not required to obtain prior authorization for NEMT services if the member is being transferred from an emergency room to an inpatient setting, or from an acute care hospital, immediately following an inpatient stay at the acute level of care, to a skilled nursing facility, an intermediate care facility or imbedded psychiatric units, free standing psychiatric inpatient hospitals, psychiatric health facilities, or any other appropriate inpatient acute psychiatric facilities. | Prior Authorization Exemption: Neither a PCS form nor a Prior Authorization is required for NEMT services if a Member is being transferred from an emergency room to an inpatient setting, or from an acute care hospital, immediately following an inpatient stay at the acute level of care, to a skilled nursing facility, an intermediate care facility or imbedded psychiatric unit, free standing psychiatric inpatient hospital, psychiatric health facility, or any other appropriate inpatient acute psychiatric facility. |
| Door-to-Door Assistance: MCPs must have processes in place to ensure door-to-door assistance is being provided. | Door-to-Door Assistance: MCPs must have processes in place to ensure door-to-door assistance is being provided and that NMT with door-to-door assistance is not being provided in lieu of NEMT services. |
| NEMT PCS Forms: Each MCP must utilize a NEMT PCS form that has been approved by DHCS and includes the required components described below to arrange for NEMT services for its members. If an MCP makes any changes to the PCS form since the last approval received from DHCS, the MCP must resubmit for approval. | NEMT PCS Forms: Each MCP must utilize a PCS form that includes the required components described below to arrange NEMT services for its Members. MCPs must authorize any PCS form that includes all the required components and meets the required clinical criteria for each individual member. A PCS form is considered complete when all required components are provided, whether entirely contained within the form itself or supplemented by supporting documentation. MCPs must work collaboratively with Providers to ensure any missing administrative information is promptly verified using available documentation, without delaying a Member’s access to NEMT services. When information is missing and is subsequently provided in supporting documentation, a new PCS form does not need to be submitted if the original PCS form along with the subsequently provided supporting documentation, contains the required information. |
| Round Trip Scheduling & Timely Access: MCPs must provide the second leg of a round-trip NEMT/NMT transportation request within an hour of the conclusion of the Member’s appointment. MCPs must provide alternate NEMT/NMT with a Provider if the original return transportation service is not provided within the one-hour timeframe. MCPs are not required to authorize or pay for NEMT/NMT services that exceed two (2) hours after the conclusion of the Member’s appointment if a Member is using the “will- call” function. | |
| 3-Hour NEMT Timeframe: NEMT services from an acute care hospital immediately following an inpatient stay at the acute level of care, to a skilled nursing facility, an intermediate care facility, an imbedded psychiatric unit, a free standing psychiatric inpatient hospital, a psychiatric health facility, or any other appropriate inpatient acute psychiatric facility, must be provided within 3 hours of the member or provider’s request. If NEMT services are not provided within the 3-hour timeframe, the acute care hospital may arrange and the MCP must cover out-of-network NEMT services. | 3-Hour NEMT Timeframe: NEMT services from an acute care hospital immediately following an inpatient stay at the acute level of care, to a skilled nursing facility, an intermediate care facility, an imbedded psychiatric unit, a free standing psychiatric inpatient hospital, a psychiatric health facility, or any other appropriate inpatient acute psychiatric facility, must be provided within three hours of the Member’s or acute care hospital’s request. If NEMT services are not provided within the three-hour timeframe, the acute care hospital may arrange out-of-network NEMT services with a Medi-Cal enrolled Provider and MCPs must cover and provide reimbursement to the hospital. MCPs are required to actively engage with hospitals during discharge planning to prevent delays that may impede discharge. MCPs must also coordinate with hospitals to prevent any coverage or claim-related issues resulting from the use of out-of-network Providers in the event that hospitals arrange transportation outside of the MCP’s Network to meet the three-hour requirement. |
| Transportation Brokers: MCPs must also ensure the contractual agreement between the MCP and the transportation broker specifies all delegated activities and delineates all related contractual, federal, and state requirements. | |
| Transportation Liaison: MCPs must have a minimum of one transportation liaison for Members and Providers to receive real-time assistance directly from the MCP to escalate transportation issues including, but not limited to, issues that can result in missed appointments or canceled appointments due to untimely transportation Providers. The liaison role cannot be delegated to a transportation broker and MCPs must have a process to triage urgent transportation calls when the Member or Provider attests that they have attempted to work with the transportation broker, but the issue remains unresolved and is time sensitive. | |
| DHCS Oversight: DHCS may impose Corrective Action plans (CAP), as well as administrative and/or monetary sanctions for non-compliance. MCPs should review their Subcontractor Agreements, Downstream Subcontractor Agreements, and Network Provider Agreements, including Division of Financial Responsibility provisions as appropriate, to ensure compliance with this APL. For additional information regarding administrative and monetary sanctions, see APL 25-007. Any failure to meet the requirements of this APL may result in a CAP and subsequent sanctions. |
We look forward to seeing your feedback/comments.
Respectfully,
Thitipong Mongkolrattanothai, MPH, Esq.
Senior Managing Counsel – Compliance & Dispute Resolution
ERN/TRAF – The Reimbursement Advocacy Firm
Tel: (714) 820-6967 Fax: (714) 995-6901
Email: thitipongmongkolrattanothai@ernenterprises.org
Enclosures:
TRAF – The Reimbursement Advocacy Firm
ERN Enterprises, INC. 3535 Hyland, Suite 130, Costa Mesa, CA 92626, Tel: 714-995-6900, Fax: 714-995-6901, www.ernenterprises.org
Attorney-Client Relationship Notice: I do not serve as legal counsel for any clients, providers, facilities, or affiliated entities of ERN Enterprises, Inc., nor for any other organization, unless expressly stated by me in writing. No attorney–client relationship is intended or shall be deemed to arise from this communication. Nothing contained herein should be construed as legal advice.
DISCLAIMER: This office advocates for medically appropriate healthcare in accordance with the principles established in Wickline v. State and the applicable laws of the governing jurisdiction. Our advocacy, consulting, representation, and training are intended to provide accurate and authoritative information to the subject matter covered. It is presented with the understanding that ERN is not engaged in the rendition of legal advice. If legal advice is required, you should consult an attorney with expertise in the relevant area of law.