20-118 Refer to Updated PCS Form to Authorize Transport for Patients

Date: 03/06/20

Updated PCS Form is available online. Use it to choose the best mode of transport for patients and avoid compliance issues

Effective immediately, use the updated Physician Certification Statement (PCS) form to document the specific transportation restrictions of a member due to a medical condition, and request non-medical transportation (NMT) or non-emergency medical transportation (NEMT) for Medi-Cal members.

The completed form will be used to assign the best means of transportation for the member. California Health & Wellness Plan (CHWP) embraces a public transit and curb-to-curb first philosophy when selecting the level of transportation service.

The physician, dentist or podiatrist responsible for providing care for the member is responsible for determining medical necessity for transportation. The physician must document the member’s limitations and provide specific physical and medical limitations that preclude the member’s ability to reasonably ambulate without assistance or be transported by public or private vehicles.

For Medi-Cal, transportation is covered only when the patient’s medical and physical condition does not allow the patient to travel by bus, passenger car, taxi, or other form of public or private conveyance.

Providers who may complete and sign the PCS form

Participating physician group (PPG) or independent practice association (IPA) Doctor of medicine (MD) Registered nurse (RN) Nurse practitioner (NP) Primary care physician (PCP)

Licensed vocational nurse (LVN) Physician assistant (PA) Discharge planner employed or supervised by the hospital, facility or physician’s office where the patient is being treated, and has knowledge of the patient’s condition when completing the form.

Download the form in two simple steps

1     Go to www.CAHealthWellness.com.

2     Search under For Providers > Manuals, Forms and Resources > Forms > Physician Certification Statement (PCS) Form – Request for Transportation (PDF).

Providers are encouraged to access CHWP’s provider portal online at www.CAHealthWellness.com for real-time information, including eligibility verification, claims status, prior authorization status, plan summaries, and more. If you have questions regarding the information contained in this update, contact CHWP at        1-877-658-0305.