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.
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:
Was transported in an emergency situation, e.g., as a result of an accident, injury or acute illness, or
Needed to be restrained, or
Was unconscious or in shock, or
Required oxygen or other emergency treatment on the way to his destination, or
Had to remain immobile because of a fracture that had not been set or the possibility of a fracture, or
Sustained an acute stroke or myocardial infarction, or
Was experiencing severe hemorrhage, or
Was bed confined before and after the ambulance trip (see note below), or
Could be moved only by stretcher
NOTE: "Bed confinement" is defined as (all three conditions must be met):
The patient is:
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.
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.
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:
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).
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.
- 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 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:
||Ground mileage, per statute mile
||Ambulance service, advanced life support, non-emergency transport, level 1 ( ALS1)
||Ambulance service, advanced life support, emergency transport, level 1 (ALS1-emergency)
||Ambulance service, basic life support, non-emergency transport, (BLS)
||Ambulance service, basic life support, emergency transport, (BLS-emergency)
||Advanced life support, level 2 (ALS2)
||Specialty care transport (SCT)
||Non-covered ambulance mileage, per mile (e.g., for miles traveled beyond closest appropriate facility)
||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:
||A0382, A0384, A0392, A0394, A0396, A0398
||A4927, A4928, A4930
|Cardiac monitoring (including EKGs)
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.
- 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.