Ohio's Wheelchair Van Certification of Necessity (ODM 03452) in 2027: Each Box, the Signer, and Manual Review

Ohio Medicaid pays for most fee-for-service wheelchair van trips only when the rider’s need for the van is on paper. That paper is form ODM 03452, a one-page form with 16 numbered boxes. This guide walks through each box, the checks to run before the first ride, and what to send when Ohio pulls a claim for manual review. For what medical necessity forms do in general and how other states handle them, see medical necessity form.

When a wheelchair van ride needs the ODM 03452

Rule 5160-15-27, in effect since August 1, 2026, says certification confirms the need for wheelchair van services and most non-emergency ambulance services. For a wheelchair van trip, the form is the ODM 03452. A non-emergency ground ambulance trip uses a different form, the ODM 01960, when Medicaid is the primary payer.

The form is for riders outside a health plan. The rule says a Medicaid managed care organization is not obliged to use this process for its members, and plan trips pay under your provider agreement (rule 5160-15-28). For plan members, follow the broker’s or plan’s own steps. The Ohio state guide shows which broker serves each plan.

These riders may call you directly. ODM’s transportation assistance flyer (July 2025) tells members who are not in managed care or MyCare Ohio, and who need a wheelchair van, that they may contact a provider directly. ODM told its Medical Care Advisory Committee on May 20, 2021 that fee-for-service transportation claims need no prior authorization, so the certification is the paper that stands behind your claim.

Trips that need no certification

The rule skips the form for trips that rules 5160-15-22, 5160-15-23, or 5160-15-24 deem necessary. For a wheelchair van, rule 5160-15-22 (effective July 1, 2021) deems one kind of trip necessary: a transfer from one hospital to a second hospital, when both of these are true.

1. The rider meets both wheelchair van criteria: the mobility device goes along from pickup to drop-off, and a standard car or common carrier is ruled out.
2. The services at the second hospital are covered by Medicaid.

Every other fee-for-service wheelchair van trip needs the form. The other two rules deem emergency ambulance trips, some non-emergency hospital-to-hospital ambulance transfers, and some air ambulance trips necessary, which matters only if you also run ambulances.

The ODM 03452, box by box

The form ODM posts is marked ODM 03452 (Rev. 7/2015) at the bottom. Here is what each box asks and what to check when the form comes back to you.

Box	What it asks	Check before the first ride
1 to 3	Rider’s full name, 12-digit Ohio Medicaid billing number, and home address	The number matches the member you verified
4 to 6	Your business name, 7-digit Ohio Medicaid provider number, and NPI if you have one	It names your company, not another provider
7	Two printed criteria the practitioner certifies by signing	Your trips must match both
8	Period Beginning Date	A date is filled in
9	Length: a number of days up to 90, or one year	One choice is marked
10	Comments or explanations	Optional
11 to 13	Practitioner’s name, Ohio Medicaid provider number if any, and 10-digit NPI	The practitioner is a type allowed to certify
14 to 16	Date of signature, name of the person signing, and signature with professional designation	Signed and dated, and a proxy signer added the practitioner’s name

Box 7: the two criteria

By signing, the practitioner certifies two statements. The rider must be accompanied by a mobility-related assistive device from the point of pickup to the point of drop-off. And travel by standard passenger vehicle or common carrier is precluded or contraindicated. These are the same two tests in rule 5160-15-22.

Ohio’s definitions (rule 5160-15-01) count four mobility devices: a manual wheelchair, a power wheelchair, a scooter, and a wheelbench, a wheelchair-like device used lying back. A cane, crutch, or walker is not on that list, and rule 5160-15-22 adds that one alone does not rule out a standard car.

A signed form does not end your checking. Rule 5160-15-27 bars payment for any trip during the certification period that does not meet the criteria, and its example is a wheelchair van trip with no mobility device. Rule 5160-15-22 names the signs that a trip met the first test: the device is dropped off or picked up with the rider at the appointment, and the rider rides in or on it between the van and the place of the appointment. Have drivers note both on the trip record.

Boxes 8 and 9: the start date and the length

The practitioner chooses a temporary certification for up to 90 days or an ongoing one for a year. Either period starts on the earlier of the signature date or the first ride. Check box 9 first. When neither choice is marked, the form says it is valid for the Period Beginning Date only, so a dialysis schedule three days a week would rest on a one-day form.

When a change in the rider’s status makes the form obsolete, the rule calls for a new one. The medical necessity form entry covers tracking end dates.

Boxes 11 to 16: the practitioner and the signature

Rule 5160-15-21 (effective July 1, 2021) lists who may certify. For either a wheelchair van or an ambulance: an advanced practice registered nurse, a doctor of medicine or osteopathy, a podiatrist, a physician assistant, or any other professional ODM recognizes as having prescriptive authority. For a wheelchair van only, the list adds a chiropractor, an LPN or RN, an occupational or physical therapist, a psychologist, a certified rehabilitation counselor, or another professional ODM recognizes as able to judge whether someone needs a mobility device.

Someone else may sign for the practitioner with proper authority or the practitioner’s approval. That person adds the practitioner’s name, their own signature, and their professional designation, such as MD, DO, DPM, RN, APN, PA, or LSW. The form allows a job title in place of a designation.

The date in box 14 must be the real date of signature. It can be no more than 180 days after the later of the first ride or the day you learned the rider had Medicaid. Nobody employed by, contracted with, volunteering for, or otherwise associated with your company may certify your trips, and false certification is Medicaid fraud. See NEMT fraud.

Checks to run before the first ride

1. Check eligibility and plan enrollment. If the rider is in a health plan or MyCare Ohio, use that plan’s process instead of the ODM 03452.
2. Decide whether the trip is deemed necessary. Only a qualifying hospital-to-hospital transfer skips the form.
3. Ask the practitioner’s office for the form. Say which length the schedule needs. A rider with standing dialysis trips needs one year, not one day.
4. Read every box against the table above when it comes back.
5. Check the signer. Confirm the title is on the rule 5160-15-21 list and that nobody tied to your company signed.
6. Log the end date on the rider’s profile the day the form arrives.
7. Watch the trips. Each ride needs the mobility device, with the rider riding in or on it to the door.
8. File the form with the rider’s trip records, not in a separate binder.

Copies, late forms, and missing forms

Copies count. A photocopy, an electronic copy, or a fax of the completed, signed, and dated form is as valid as the original. Ohio’s transportation chapter defines a signature as a mark made by hand or in any other legally valid manner.

A form does not travel. It certifies one rider for one provider, and rule 5160-15-27 says certification cannot be transferred between riders or between providers. If a rider switches to your company, ask for a new form that names you. A patently incorrect form is invalid even when it is signed.

If the practitioner never sends it back, you may bill with an incomplete form after three attempts, waiting at least 30 calendar days after each one, with no response. Keep proof of each attempt. The signature date never extends your filing deadline: ODM must receive the claim within 365 days of the ride (rule 5160-1-19). See timely filing limit.

Manual review: what sends a claim there and what to include

Manual review means an ODM employee examines the claim by hand to decide whether it meets payment criteria (rule 5160-15-01). A wheelchair van claim goes there in three cases.

• The trip pair is not on the exempt list. The appendix to rule 5160-15-28, enacted July 10, 2026, lists the origin and destination pairs that skip manual review. Home to home (RR) is not on it. See origin and destination modifiers for the letters.
• A point is not otherwise specified. The U5 modifier always requires manual review.
• The trip leaves the region. A trip from or to a place outside Ohio and the states that border it is reviewed by hand (rule 5160-15-26).

Rule 5160-15-25 says a request for manual review includes:

1. A completed practitioner certification form, for any claim other than emergency ambulance service.
2. A complete description of the service, the date of service, the trip origin and destination, any special services, and the reason for an attendant, when one rode along.
3. Details of any other circumstances ODM should weigh.

Two related limits apply to the same claims. Mileage on a non-emergency trip longer than 50 miles from pickup is paid for 50 miles unless you keep documentation that justifies the distance (rule 5160-15-26). And an attendant, billed on T2001 at a maximum of $15.00, is paid only when needed for safe transport and documented (rule 5160-15-22 and the July 10, 2026 appendix).

How long to keep the form

Rule 5160-15-27 lists what you keep: current certificates for crew members and attendants, completed certification forms, copies of manual review requests, the trip details the ambulette rules require, and the Medicaid details. Those are the vehicle used, the attendant’s name, the rider’s Medicaid number, and, on non-emergency trips, the rider’s signature.

For how long, the rule points to chapter 5160-1. The provider agreement rule (5160-1-17.2, effective September 19, 2019) keeps records for six years from the date you receive payment, or until an audit started in that time is finished. The ambulette rule (4766-3-05, effective August 1, 2017) keeps client transportation records for seven years after each trip. Since the form backs every trip in its period, keep it at least seven years past the last trip it covers, longer if a payment came more than a year after its trip, and until any open audit is finished. NEMT trip documentation covers the rest of the file, and Medicaid audits for NEMT covers what auditors ask for.