Printer Friendly Version

Section: Ancillary Services
Number: Q-1
Topic: Ambulance Services (Medical Transportation)
Effective Date: August 6, 2007
Issued Date: June 15, 2009
Date Last Reviewed: 08/2007

General Policy Guidelines

Indications and Limitations of Coverage

Ambulance transportation is a benefit under many, but not all, of the Plan's products. When a benefit, coverage is made in accordance with all appropriate contractual provisions and limitations.

This policy addresses general guidelines applicable to ambulance services. It should be used as a reference source in conjunction with the member’s benefits, the network provider’s agreement with the Plan, and any applicable ambulance billing guidelines.

Medical Necessity
To be covered, ambulance transportation must be medically necessary. Medical necessity is established when the patient's clinical condition is such that the use of any other method of transportation, such as taxi, private car, or other type of vehicle would be contraindicated (i.e., would endanger the patient's medical condition).

The patient's condition at the time of the transport is the determining factor in whether a trip will be covered. The fact that the patient is elderly, has a positive medical history, or cannot care for himself/herself does not establish medical necessity.

Payment will not be made for ambulance service when an ambulance was used simply for convenience or because other means of transportation was not available.

Reimbursement may be made for expenses incurred by a patient for ambulance services that meet the following conditions:

  1. Was transported in an emergency situation, e.g., as a result of an accident, injury or acute illness, or 
  2. Needed to be restrained, or
  3. Was unconscious or in shock, or
  4. Required oxygen or other emergency treatment on the way to his destination, or
  5. Had to remain immobile because of a fracture that had not been set or the possibility of a fracture, or
  6. Sustained an acute stroke or myocardial infarction, or
  7. Was experiencing severe hemorrhage, or
  8. Was bed confined before and after the ambulance trip (see note below), or
  9. Could be moved only by stretcher

NOTE: "Bed confinement" is defined as (all three conditions must be met):

The patient is:

  • unable to get up from bed without assistance;
  • unable to ambulate; and
  • unable to sit in a chair or wheelchair.

Services that do not meet the medical necessity guidelines outlined on this policy will be considered not medically necessary. Effective January 26, 2009, a participating, preferred, or network provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement should be maintained in the provider's records.

Vehicle and Crew Requirements
Any vehicle used as an ambulance must be designed and equipped to respond to medical emergencies, and, in non-emergency situations, be capable of transporting members with acute medical conditions. The vehicle must comply with state or local laws governing the licensing and certification of an emergency medical transportation vehicle. At a minimum, the ambulance must contain a stretcher, linens, emergency medical supplies, oxygen equipment, and other lifesaving emergency medical equipment and be equipped with emergency warning lights, sirens, and telecommunications equipment as required by state or local law. This should include, at a minimum, one two-way voice radio or wireless telephone.

If the previous criteria are not met, the service will be denied as noncovered. A network provider can bill the member for the denied service.

No Transport
If no transport of a member occurs (A0998), no covered service is rendered. Therefore, payment will not be made to the ambulance company. This applies to situations in which the member refuses to be transported, even if medical services are provided prior to loading the member onto the ambulance (e.g., BLS or ALS assessment). A network provider can bill the member for this denied service.

Destination Requirements
For an ambulance trip to be covered, the patient must be transported to the closest local facility that has appropriate facilities for treatment. The term "appropriate facilities" means that the institution is generally equipped to provide the needed hospital or skilled nursing care for the illness or injury involved. In the case of a hospital, it also means that a physician is available to provide the necessary care required to treat the patient's condition.

Pronouncement of Death
No payment will be made if the member was pronounced dead prior to the time the ambulance was called. The following scenarios apply to payment for ambulance services when the member dies:

  • If the member is pronounced dead after the ambulance is called (before or after the ambulance arrives at the scene), but before they are loaded onboard the ambulance:

Payment may be made for a BLS base rate; no mileage adjustment will be made. Use the QL modifier (patient pronounced dead after the ambulance was called).

  • If the member is pronounced dead after being loaded into the ambulance (regardless of whether the pronouncement is made during or subsequent to the transport):

Payment is made following the usual rules of payment as if the member had not died. This scenario includes a determination of "dead on arrival" (DOA) at the facility to which the member was transported.

NOTE:
Notwithstanding the member's apparent condition, the death of a member should be recognized only when the pronouncement of death is made by an individual who is licensed or otherwise authorized under state law to pronounce death in the state where such pronouncement is made.

ALS and BLS Contractual Agreements
In situations where a BLS (Basic Life Support) supplier provides the transport of the member and an ALS (Advanced Life Support) supplier provides a service that meets the definition of ALS intervention (e.g., ALS assessment, Paramedic Intercept services), the BLS supplier may bill the higher ALS rate, only if there is a written agreement between the BLS and ALS suppliers. Suppliers must provide a copy of the agreement or other such evidence (e.g., signed attestation) upon request.

Paramedic Intercept
Paramedic intercept services (A0432, S0207, S0208) are ALS services provided by paramedics who are not part of the ambulance entity that is providing the actual patient transportation. Payment may be made for medically necessary paramedic intercept services.

Ambulance Transportation Services
Reimbursement for all ambulance suppliers will be based on a base rate for transportation, which includes all supplies. A separate charge is payable for mileage.

Ambulance suppliers should report one charge reflecting all services and supplies, with a separate charge for mileage. Codes that can be reported are:

Code

Description

A0425  Ground mileage, per statute mile
A0426  Ambulance service, advanced life support, non-emergency transport, level 1 ( ALS1) 
A0427  Ambulance service, advanced life support, emergency transport, level 1 (ALS1-emergency) 
A0428  Ambulance service, basic life support, non-emergency transport, (BLS)
A0429  Ambulance service, basic life support, emergency transport, (BLS-emergency) 
A0433  Advanced life support, level 2 (ALS2) 
A0434  Specialty care transport (SCT) 
A0888  Non-covered ambulance mileage, per mile (e.g., for miles traveled beyond closest appropriate facility)  
A0999  Unlisted ambulance service (complete narrative description required, payment can be made on an individual consideration basis)


Other services billed in addition to the base rate will be denied as an integral part of the actual transportation. They include the following codes:

Supply codes   A0382, A0384, A0392, A0394, A0396, A0398 
Waiting time  A0420
Oxygen  A0422
Extra Attendant  A0424 
Protective garments  A4927, A4928, A4930  
Cardiac monitoring (including EKGs)  93000-93010, 93040-93042 
Pulse Oximetry 94760, 94761 

Miscellaneous

  • Individual procedure codes for service and mileage, along with the number of miles, must be reflected on the claim.

  • Ambulance suppliers are required to retain documentation on file supporting all ambulance services (i.e., trip sheets).

  • When multiple units respond to a call for services, payment will be made to the entity that provides the transport for the member. The transporting entity should bill for all services furnished.

  • More than one patient may be transported, e.g., from the scene of a traffic accident. The billed amount should be prorated by the number of patients in the ambulance.

  • When multiple patient transports are reported, the statement "multiple patients" and the number transported must be documented.

  • Based upon the state licensure requirements for an ambulance vehicle and crew members, cardiac monitoring is considered an ALS specialized service. Therefore, it is not recognized as a service performed in conjunction with a BLS transport.

  • Payment will not be made for ambulance services that are provided for patient or family convenience.

  • Payment will not be made for ambulance night differential charges for ambulance transport provided between the hours of 7pm and 7am (A0999), as it is considered an inherent part of the base rate for ambulance transport. Code A0999 will be denied as not covered when submitted for ambulance night differential charges for ambulance transport. A network provider cannot bill the member for the denied service.

Refer to Medical Policy Bulletin Q-5 for guidelines specific to air ambulance services.

NOTE:
Coverage for Ambulance Services is determined according to individual or group customer benefits.

Coverage for wheelchair van transport (A0130) and stretcher van transport (T2005, T2049) is determined according to individual or group customer benefits.

NOTE:
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Procedure Codes

930009300593010930409304193042
9476094761A0130A0225A0380A0382
A0384A0390A0392A0394A0396A0398
A0420A0422A0424A0425A0426A0427
A0428A0429A0432A0433A0434A0888
A0998A0999A4927A4928A4930A9270
S0207S0208S0215T2005T2049 

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

Local professional ambulance transport services to or from the nearest hospital equipped to adequately treat the member's condition are covered when medically appropriate, and:

  • associated with covered hospital inpatient care;
  • related to medical emergency or accidental injury; or
  • associated with covered hospice care.
NOTE:
We also cover medically necessary emergency care provided at the scene when transport services are not required.

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

References

Ambulance Billing Guide, Appendix F, Medicare Part B Reference Manual, February 2006, http://www.highmarkmedicareservices.com/partb/bguides/pdf/bg-amb.pdf

View Previous Versions

[Version 009 of Q-1]
[Version 008 of Q-1]
[Version 007 of Q-1]
[Version 006 of Q-1]
[Version 005 of Q-1]
[Version 004 of Q-1]
[Version 003 of Q-1]
[Version 002 of Q-1]
[Version 001 of Q-1]

Table Attachment

Text Attachment

Procedure Code Attachments

Diagnosis Codes

Glossary





This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Mountain State Blue Cross Blue Shield plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Mountain State Blue Cross Blue Shield (MSBCBS) retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of MSBCBS. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.



back to top