Physician Certification Statement (PCS form)

Each plan uses its own form, approved by DHCS, but every one must carry at least:

• Function limitations justification: the member’s specific physical and medical limitations that rule out walking without help or riding in a public or private vehicle.
• Dates of service needed: a start and an end date, for at most 12 months.
• Mode of transportation needed: ambulance, litter van, wheelchair van or air.
• Certification statement: the provider certifies that medical necessity decided the type of transport.

A physician, dentist, podiatrist, mental health or substance use disorder provider, or a physician extender (physician assistant, nurse practitioner or certified midwife) can prescribe NEMT. The plan reviews the form itself; it can’t hand that review to a broker. Once the treating provider has chosen the mode, neither the plan nor the broker can change it, unless the form ticks more than one mode, in which case the lowest-cost one may be used.

When a member needs urgent care and no form could be sent beforehand, the plan can approve the ride by phone, and the provider sends the PCS afterwards. Some plans route the form through their broker’s office; Anthem Blue Cross’s Medi-Cal form, for example, is sent to ModivCare.

The van that shows up must match the mode on the form, and the trip must fall inside its dates. Providers keep the PCS dates with the rider so a standing order doesn’t run past an expired form, and print the authorization number on trip sheets and claims. In fee-for-service Medi-Cal the same role is played by a prescription attached to a TAR.