Current Status: ActiveDate Issued:PolicyStat ID: 43802719/16/1998Last Approved Date:12/20/2017Last Revised Date:12/20/2017Next Review:12/19/2020Owner:Dana James:21011004-QualityAssurance CoordinatorPolicy Area:Wraparound (REACH,O'YEAH)- VendorReferences:#029- Transportation ServicesPOLICYIt is the policy of Wraparound Milwaukee/Family Intervention Support Services (FISS) that an adult be presentwhen children under the age of 12 are being transported. Escorts are adults age 18 or older who may includea parent, family member, foster parent, caregiver, legal guardian or other individual as authorized by the childand family team; paid Providers may not be used as escorts. The escort is to remain with the child from thechild's pick-up location and stay with the child through arriving at the drop-off location.COPYNOTE: This policy utilizes the term "Care Coordinator", which applies to Wraparound and REACH CareCoordinators, FISS Case Managers and O-YEAH Transition Coordinators. The term "Youth" is used in thispolicy and applies to the enrollee in the program, whether a child, adolescent, or young adult.PROCEDUREA. Types of Transportation Arrangements that can be madeThe Care Coordinator can access transportation services for enrollees/families through one or more ofthe four ways listed below. Transportation Service reimbursement should be sought through themeans identified in #1, #2, & #3 prior to seeking Transportation Services through #4.1. Care Coordination / Case Management Agency – Bus TicketsThe Care Coordinator can assist the enrollee/family with meeting the transportation needs of theenrollee/family by arranging for access to bus tickets and in some cases, bus passes.2. Medicaid – Billable TransportationWhen the enrollee's transportation needs can be covered under Medicaid, the Care Coordinatorshould contact Medical Transportation Management Inc. (MTM) to determine eligibility. If eligible,authorization for these transportation services should not be entered on a ServiceAuthorization Request (SAR). MTM website is needs covered under Medicaid are limited to medical-related appointments, doctorappointments, dental/vision appointments, therapy appointments, transportation to Medicaid DayTreatment Programs and any other justifiable medical service.A Medicaid billable transportation service can also be used for siblings/parents who have a physicaldisability or Medicaid diagnosis of SED. The Care Coordinator should contact MTM to determineeligibility.#029- Transportation Services. Retrieved 12/21/2017. Official copy at .Copyright 2017 Milwaukee County Behavioral HealthPage 1 of 7

When an enrollee is able to safely use an automobile, bus or taxi, and is not eligible for MedicaidTransportation through MTM, the Care Coordinator may authorize one of the options identifiedbelow.3. School Mandated TransportationA youth who is identified as having special education needs and in need of transportation to schoolor a Medicaid Day Treatment Program should have this identified and supported in theirIndividualized Educational Plan (IEP) and the Wraparound Plan of Care (POC)/Future's Plan. If it issupported in the youth's IEP, the youth's school district is responsible for the cost oftransportation. If it is not on an IEP and the youth will be attending a Medicaid Day Treatmentprogram, transportation should be arranged through MTM.4. Network Provider TransportationTransportation and Taxi services are also available through the Wraparound Milwaukee ProviderNetwork. Additional information regarding the use of Wraparound Milwaukee Provider Networktransportation services is below.B. Network Provider Transportation - Care Coordinator / Case Manager Responsibilities1. ReferralsIt is the responsibility of the Care Coordinator to complete and fax a copy of the appropriateTransportation Referral Form to the Transportation Provider prior to the provision of services.COPYa. Referral Forms and SAR Entry - Transportation ProvidersThe "REFERRAL FOR TRANSPORTATION" form (see Attachment 1) available on the"FORMS" tab in Synthesis (Wraparound Milwaukee's Information Management System) iscompleted for enrollees/family members referred for services from Wraparound MilwaukeeProvider Network Transportation Providers. The service recipient(s) is identified as the "Name ofthe Person to be Transported" on the referral form. The Care Coordinator must fax thecompleted form to the Provider Network Transportation service provider prior to the provision ofservice.The Care Coordinator must also enter a Service Authorization Request (SAR) in Synthesis priorto the service being provided.b. Referral Forms and SAR Entry – American United TaxiThe "REFERRAL FOR TRANSPORTATION-AMERICAB" (see Attachment 2) available on the"Forms" tab in Synthesis is completed for enrollees/family members referred for Taxi services.The Care Coordinator must fax the referral form to American United Taxi prior to the provision ofservices. The referral form also serves as the authorization for payment for American UnitedTaxi. There is NO NEED TO ENTER A SAR for services provided by American UnitedTaxicab as service costs vary for each ride and all Taxi service related data entry is completedby Wraparound Milwaukee Finance Staff.2. Service CancellationsIf a transportation request needs to be canceled for any reason, it is the responsibility of the CareCoordinator or designated Child & Family Team member to notify the Transportation Providerregarding the cancellation. The call should be made as soon as the need to cancel becomes evident.This includes cancellation of "one time" and "repeat" rides. When canceling repeat taxi rides, theCare Coordinator must fax to American Taxi the original Referral form with "cancel all rides" writtenon the form.#029- Transportation Services. Retrieved 12/21/2017. Official copy at .Copyright 2017 Milwaukee County Behavioral HealthPage 2 of 7

3. Changes in Enrollee/Service Recipient Contact InformationThe Care Coordinator is responsible for immediately notifying the Transportation/Taxi Provider ofchanges in the enrollee's status, address, and any changes related to the information on theTransportation Referral Form (such as contact persons names and numbers, etc.) including thenames of contact persons at the clinics / facilities where the enrollee/service recipient is beingtransported for services. The Care Coordinator is also responsible for sharing Transportation/Taxicontact and ride schedule information with family members/custodians and service providers that willbe required to interface with the Transportation Provider(s). This is important, as these contactpersons will be responsible for monitoring the enrollee/family member's reception by theTransportation/Taxi service provider, including seeing the enrollees off, signing TransportationProvider trip verification logs and following up with Transportation Providers if they are running late.4. Pre-Authorization of Transportation Services - Extended TripsTransportation service authorizations for trips that extend beyond 25 miles from the pick-up locationto the destination or where the pick-up location is more than 25 miles from outside the City ofMilwaukee require pre-authorization by Wraparound Milwaukee Finance or Quality AssuranceDepartment in advance of travel. Care Coordinators must submit the following information: Enrollee nameCOPY Name(s) of the individual(s) to be transported and their relationship to the enrollee Explanation of need Total number of trips for the month Expected duration for the service to include start and end dates Pick-up address Destination address Transportation Provider name Approximate total travel distance Is individual eligible for transportation through Medicaid MTMThe Care Coordinator will be notified via email with the authorization decision. Authorization is forcurrent month and through the next month. Trips beyond this time period must be resubmitted for anextension.C. Transportation Provider Responsibilities1. Criminal History / Criminal Background CheckAll Transportation Providers must comply with the Background Check requirements outlined in theWraparound Milwaukee Fee-for-Service Agreement and Caregiver Background Check PolicyDHHS-001. This includes submitting driver background checks to the Wraparound MilwaukeeProvider Network for review if the Department of Justice report shows any findings other than "norecord found".2. Valid Drivers License and Driver's AbstractTransportation Providers must maintain copies of current valid Wisconsin driver's licenses for alldrivers. A Driver's Abstract must be conducted on each potential driver to assure a clean drivingrecord (see reference for Vehicle/Driver Record Information Request). The Transportation Providershould forward reports with significant adverse activity to the Wraparound Milwaukee ProviderNetwork for review.#029- Transportation Services. Retrieved 12/21/2017. Official copy at .Copyright 2017 Milwaukee County Behavioral HealthPage 3 of 7

Drivers of vehicles that are designed to serve 16 or more passengers, including the driver, must havea Commercial Driver's License – Minimum Class C.3. Insurance CoverageTransportation Providers must comply with all insurance requirements identified in the WraparoundMilwaukee Fee-for-Service Agreement.4. Vehicle Safety/MaintenanceA copy of a Vehicle Inspection Report for each transportation vehicle used by a TransportationProvider is to be submitted during the application process. As vehicles are added to the fleet, anInspection Report must be obtained prior to using the vehicle in transporting enrollees/families. Allvehicles inspected must have a sticker with the current year verifying the inspection. Vehicleinspection reports are to be made available to Wraparound Milwaukee upon request.All vehicles used to provide services through the Wraparound Milwaukee Provider Network must bein good repair and equipped with functional seat belts for all passengers, a basic first aid kit andproperly maintained fire extinguisher. The driver and all passengers must wear seat belts that areproperly secured at all times during transport.COPY5. Dispatch/CommunicationThe Transportation Provider must have an agency staff person available to receive or make callsuntil the last enrollee of the day has been dropped off and received by a responsible caregiver.All vehicle drivers must have some means of communication with the Provider Agency (i.e., cellphone, dispatch radio, etc.) while transporting enrollees. These communication devices must be ingood working order and turned on at all times during transport.6. Referrals and Provider Emergency Plana. Providers must ensure that they receive a referral form that has been completed by the CareCoordinator prior to the provision of service.b. Providers are required to maintain up-to-date emergency contact information for all WraparoundMilwaukee/FISS service recipients. The Transportation Provider must also have a writtenAgency "Emergency Plan" (policy and procedure) for the driver to follow if an accident shouldoccur, if a child becomes ill during transport or if any other "emergency" situation should arise.7. Transportation Provider Billinga. Transportation Providers are paid on a "per trip" basis. The "per trip" rate (established in theFee-for-Service Agreement) is based on one passenger for a trip of up to 5.9 miles.b. Transportation Provider can be paid for up to four (4) additional passengers per trip (rateestablished in the Wraparound Milwaukee Fee-for-Service Agreement) if authorized by the CareCoordinator on the "REFERRAL FORM FOR TRANSPORTATION." Providers report additionalpassengers on the daily Trip Logs entered in Synthesis.c. Escorts traveling with children under the age of 12 may be claimed as an additional passengerand may be billed accordingly. Providers may only invoice for one escort per trip. The names ofall escorts must be listed on the Transportation Signature Log sheet under "Person beingTransported," and in the "Relationship to Enrollee" column the word "escort" must be written.d. Transportation Providers are paid a mileage adjustment for trips of 6.0 miles or more. This#029- Transportation Services. Retrieved 12/21/2017. Official copy at .Copyright 2017 Milwaukee County Behavioral HealthPage 4 of 7

mileage adjustment is processed automatically by Finance Staff based on Trip Logs entered inSynthesis and payment is based on the rate established in the Wraparound Milwaukee Fee-forService Agreement.e. Transportation Providers are required to use Synthesis to submit monthly billing and enter triplog. Provider training on the Wraparound Milwaukee online billing system is available throughthe Wraparound Milwaukee Finance Department. Providers bill for the number of trips provided.Wraparound Milwaukee Finance Department staff use information entered on each Trip Log todetermine adjustments due to the Provider for additional passengers and/or mileage.f. Transportations Providers should work with the service recipient's Care Coordinator to minimizeappointment "NO SHOWS". Transportation Providers are reimbursed for up to 2 "NO SHOWS"per client per month. Payment for "NO SHOWS" is calculated by Wraparound MilwaukeeFinance staff and is based on the Provider entering "zero" as the number of passengers on thetrip log. Transportation Providers CANNOT bill a "no show" when they arrive late for a pick-upand other arrangements have already been made to transport the passenger.8. Documentation / Signature LogsTransportation Providers must maintain a "SIGNATURE LOG" for ALL rides billed to WraparoundMilwaukee and FISS. A "SIGNATURE LOG" (see Attachment 3) is available from WraparoundMilwaukee in Synthesis, which the Transportation Provider can use to satisfy this requirement.COPYThe Signature Logs must contain the following: Transportation Provider Name Enrollee Name Month of Service and Year Type of Trip Date of Transport – date must include month/day/year Service Recipient Start Time End Time Trip Number (if using Synthesis generated Signature Log) Location Number of riders Driver Initials Responsible Adult Signature Relationship of Signature to Enrollee9. Transportation Log / Documentation Maintenancea. The Transportation Provider must keep ONE (1) Log per enrollee/per month.b. The Transportation Provider can determine how they prefer to file their Logs at their Agency(i.e., per month/year, per enrollee, etc.) for active enrollees. If the Log is not being kept in theenrollee file during the time services are being actively provided, the Logs must be filed in theenrollee's file after the last date of service.#029- Transportation Services. Retrieved 12/21/2017. Official copy at .Copyright 2017 Milwaukee County Behavioral HealthPage 5 of 7

c. Referral Forms and other relevant enrollee related documentation must be kept in an organizedmanner and be easily accessible. Each enrollee must have his or her own file. All enrolleerelated information is confidential and all enrollee files must be kept in a safe and securecabinet or room. Enrollee files of minors must be maintained at the agency until the youth turns19 or 7 years past the last date of service, whichever is longer. Enrollee files of adults (i.e., FISSenrollees) must be maintained for 7 years after the last date of service.10. Pick-Ups, Drop-Offs and Running Latea. Pick-Up and Drop-OffAll enrollees (minors) must be received by an identified / responsible adult caregiver whenbeing dropped off at an agency, home, appointment, etc.b. Running LateIf a Transportation Provider's driver anticipates that they are going to be more than 15 minuteslate for a pick-up, they must notify the service recipient that they will be picking up or theidentified contact person (i.e., the Therapist, if the youth is at a counseling session) responsiblefor the enrollee at that pick-up location of the anticipated late arrival time. It is also permissiblefor the Transportation Provider Dispatcher to make the call to the enrollee/contact person.COPYThe driver/dispatcher should inform the enrollee/contact person of the situation and indicate thetime that the driver will arrive. If this arrival time is acceptable to the enrollee/contact person,then no further arrangements need to be made. In the case of a late transport for a minor, thecontact person should then notify the identified caregiver of the situation and remain with theyouth to provide supervision.In a situation in which 15 minutes have lapsed and the enrollee/contact person has not receiveda call from the Transportation Provider's driver indicating that they are running late, the enrollee/contact person should initiate a call to the Transportation Provider to inquire about the arrivaltime. If the Transportation Provider cannot be reached, then the enrollee /contact person willneed to decide if they want use an alternate means of transportation.If returning from an appointment, the contact person of the agency waiting for the Transportationservices should refer to the service recipient's Referral Form for caregiver phone numbers,emergency contacts and Care Coordinator phone numbers to assist them in coordinating analternate means of transportation.If an alternate means of transportation is sought and arranged, and the TransportationProvider's driver arrives in the meantime, the enrollee/contact person (with permission from theguardian/caregiver in the case of a minor) should inform the individual with whom arrangementshave been made and they should collaboratively determine if the Transportation Provider'sdriver should still do the transport. If it is determined that the Transportation Provider's drivershould not transport the enrollee, then the Transportation Provider cannot bill for that transportor for the contact as a NO SHOW.11. Physical Contact (Touching) / HarassmentUnder no circumstances should a Transportation Provider's driver have physical contact with anenrollee (exception to the above applies when the enrollee needs assistance entering ordisembarking from the van due to a disability). Drivers may not have personal or other contact withservice recipients outside the provision of the authorized service (i.e., outside the work environment).#029- Transportation Services. Retrieved 12/21/2017. Official copy at .Copyright 2017 Milwaukee County Behavioral HealthPage 6 of 7

12. Scope of ServiceTransportation Providers/Drivers are not authorized to provide services to enrollees and their familiesoutside of their role as a Transportation Provider. If an enrollee, parent/guardian, family member,service provider or team member requests that the provider perform non-related transportationservices, the provider is instructed to contact the Care Coordinator immediately to inform them of thesituation. If unresolved or otherwise necessary, providers should call the Care Coordinator'ssupervisor or Wraparound Milwaukee Administration.References1. Forward Health Non-emergency Medical Transportation Manager f/2013-32.pdf2. MTM Resources and Links to Parental Consent Forms: /3. Wisconsin DMV Vehicle/Driver Record Information Request: pdf1: Referral for Transportation2: Referral for Transportation-AMERICABCOPYAttachments:3: Signature LogApproval SignaturesStep DescriptionApproverDateMichael Lappen: 11008000-BHD Administrator12/20/2017MaryJo Meyers: 11003003-Director Wraparound Program12/20/2017Pamela Erdman: 12008005-Placement Resources Manager12/19/2017Dana James: 21011004-Quality Assurance Coordinator12/18/2017#029- Transportation Services. Retrieved 12/21/2017. Official copy at .Copyright 2017 Milwaukee County Behavioral HealthPage 7 of 7

Wraparound MilwaukeeTRANSPORTATION REFERRAL FORMEnrollee Name:DOB:.Enrollee, James1/1/99Age:Initial Referral Date:19.0Gender:11/25/14FemaleID Number::Referred by:50032Phone Number(s):Email:Current Referral Date11/25/2014Transportation Vendor RequestedLS Transportation, Inc.Phone number for driver to call(414) 555-1234Name of person(s) to be transportedJames EnrolleeRelationship to youthReason for transportation requestSelfNon-therapy ApptIf 'Other' selected as Reason - describePick Up Date11/28/2014Pick Up Time12:30:00 PMPickup LocationHome 1234 Hope Drive, Milwaukee, WI 53201Drop Off Time1:15:00 PMDropoff LocationOwen's Place: 4610 West Fond du Lac, Milwaukee, WI 53216How often will trips occurWeeklyIf this is a recurring trip, specify detailsEvery Friday at 12:30PM beginning 11/28/2014 and ending 2/6/2015Trip TypeRound TripIf a round-trip ride, second pick-up time2:00:00 PMAmerican Taxi DOES NOT ACCEPT ADVANCE REQUESTS for the Round Trip Return Ride. Thepassenger needs to call 220-5000 for a Taxi when ready for a return ride.Emergency Contact NameJane Enrollee (mother)Emergency Contact Phone(414) 555-4567Medical Concerns, if anyNoneSafety Concerns / Special AccommodationsNoneWheelchair Needed?NoSMV Form StatusNoneName of escortJane EnrolleeOther Notes, if anyNone

Transportation Request from Wraparound MilwaukeeEnrollee Name:DOB:.Enrollee, JamesAmerican United TaxicabFax to 414-220-50171/1/99Referred by:Name/Phone:EmailAcct. No. WM 15ID Number:Phone number for driver to call(414)555-1234Name of person(s) to be transportedJames EnrolleeRelationship to youthSelfReason for transportation requestHome PassIf 'Other' selected as Reason describePickup Date11/29/2014Pickup LocationTrue Living Group Home 7890 N 35th Street, Milwaukee, WI53218Time of Appointment1:00:00 PMTime of Pick-up12:30:00 PMDropoff LocationHome 1234 Hope Avenue, Milwaukee, WIHow often will trips occur?Single RideIf Multiple Days Per Week Selected,list days of the weekTrip TypeOne-WayEmergency Contact NameJane EnrolleeEmergency Contact Phone(414) 555-4567Medical Concerns, if anyN/ACare Coordinators Note: American United Taxicab requires that a Transportation Request form be faxedto them FOR ALL NEW RIDES AND RIDES WHERE THE PICK-UP TIME VARIES.50032

Transportation Signature LogEnrollee Name:Wraparound MilwaukeeVendor Name:Service Month:.Enrollee, JamesPossible Trips (Reference # of Trip in Detail Lines)Trip # Trip Name1Owen's PlaceDateLocation 1HomePerson Being Transported:Check ifIf NOT enrollee- list rider name(s)ClientLocation 2Owen's PlaceStartTimeEndTimeTrip #(fromabove )Location # Riders(use 0 for1 or 2no-shows)DriverInitialsResponsibleAdult SignatureRelationship to enrollee (notreq'd if enrollee signs)

program, transportation should be arranged through MTM. 4. Network Provider Transportation Transportation and Taxi services are also available through the Wraparound Milwaukee Provider Network. Additional information regarding the use of Wraparound Milwaukee Provider Network transportation services is below.