Tuesday, August 23, 2016

Definition - What is Emergency, Medical necessity


Emergency - A serious medical condition or symptom resulting from Injury, Sickness or [1Mental Illness][2mental illness] which is both of the following:

• Arises suddenly

• In the judgment of a reasonable person, requires immediate care and treatment, generally received within 24 hours of onset, to avoid jeopardy to life or health

Medically Necessary (UHIC 2011 COC) - health care services provided for the purpose of preventing, evaluating, diagnosing or treating a Sickness, Injury, [Mental Illness,] [mental illness,] substance use disorder, condition, disease or its symptoms, that are all of the following as determined by us or our designee, within our sole discretion.

• In accordance with Generally Accepted Standards of Medical Practice

• Clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for your Sickness, Injury, [Mental Illness,] [mental illness,] substance use disorder, disease or its symptoms

• Not mainly for your convenience or that of your doctor or other health care providerNot more costly than an alternative drug, service(s) or supply that is at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of your Sickness, Injury, disease or symptoms

Generally Accepted Standards of Medical Practice are standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, relying primarily on controlled clinical trials, or, if not available, observational studies from more than one institution that suggest a causal relationship between the service or treatment and health outcomes.

If no credible scientific evidence is available, then standards that are based on Physician specialty society recommendations or professional standards of care may be considered. We reserve the right to consult expert opinion in determining whether health care services are Medically Necessary. The decision to apply Physician specialty society recommendations, the choice of expert and the determination of when to use any such expert opinion, shall be within our sole discretion.

We develop and maintain clinical policies that describe the Generally Accepted Standards of Medical Practice scientific evidence, prevailing medical standards and clinical guidelines supporting our determinations regarding specific services. These clinical policies (as developed by us and revised from time to time), are available to Covered Persons on [myuhc.com] or by calling Customer Care at the telephone number on your ID card, and to Physicians and other health care professionals on UnitedHealthcareOnline.

Saturday, August 20, 2016

What are situation ambulance service will not be paid ?

Coverage Limitations and Exclusions

The following services are not eligible for coverage:

1. Ambulance services from providers that are not properly licensed to be performing the ambulance services rendered.

2. Air ambulance that does not meet the covered indications in the Air Ambulance criteria listed above.

3. Non-ambulance transportation. Non-ambulance transportation is not covered even if rendered in an Emergency situation. Examples include but are not limited to commercial or private airline or helicopter, a police car ride to a hospital, medi-van transportation, wheel-chair van, taxi ride, bus ride, etc.

4. Ambulance transportation when other mode of transportation is appropriate. Except as indicated under the Indications for Coverage section of this policy, ambulance services when transportation by other means would not endanger the enrollee’s health, are not covered.

5. Ambulance transportation to a home, residential, domiciliary or custodial facility is not covered.

6. Ambulance transportation that violates the notification criteria listed in the Indications for Coverage section above.

7. Ambulance transportation for patient convenience or other miscellaneous reasons for patient and/or family. Examples include but are not limited to:

a. Patient wants to be at a certain hospital or facility for personal/preference reasons;

b. Patient is in foreign country, or out of state, wants to come home to for a surgical procedure or treatment (this includes those recently discharged from inpatient care);

c. Patient is going to a routine service and is medically able to use another mode of transportation but can’t find it;

d. Patient is deceased (ie, transportation to the coroner’s office or mortuary)

8. Ambulance transportation deemed not appropriate. Examples include but are not limited to:

a. Hospital to home

b. Home to physician’s office

c. Home (eg. residence, nursing home, domiciliary or custodial facility) to a hospital for a scheduled service

Additional Information:

• If the patient is at a Skilled Nursing Facility/Inpatient Rehabilitation Facility and has met the annual day/visit limit on Skilled Nursing Facility/Inpatient Rehabilitation Facility Services, ambulance transports (during the non-covered days) are not eligible.

Thursday, August 18, 2016

Non network Ambulance would be covered?

Benefit Level for Non-Emergency Ambulance:

The applicable benefit for eligible non-Emergency ambulance transportation depends on the patient pick-up location (origin) as follows:

1. If the patient is inpatient and is transported from a hospital to another hospital or inpatient facility, coverage levels for these ambulance services may vary. Please refer to the enrollee’s specific plan document to determine benefits. The following are UHIC examples for inpatient ambulance transfer:

a. UHIC 2001 COC: The Hospital Inpatient Stay section of the COC

b. UHIC 2007 and 2011 COC: the Ambulance Services section of the COC

2. If the patient is in a sub-acute setting and is transported to an outpatient facility and back (outpatient hospital, outpatient facility, or physician’s office), these ambulance services are covered under the benefits that apply to that sub-acute setting. For example, if the patient is at a Skilled Nursing Facility, the ambulance transport to an outpatient facility (dialysis facility, or radiation whether or not it is attached to a hospital) and back is covered under the Skilled Nursing Facility/Inpatient Rehabilitation Facility Services section of the COC.

Enrollee Pre-Service Notification Requirements for Non-Emergency Ambulance:

• If UHIC initiates the non-Emergency ambulance transportation, enrollee notification is not required.

• If UHIC does not initiate the non-Emergency ambulance transportation certain plans may require the enrollee or the provider to call in for notification. Please see the enrollee-specific plan documents for details on the notification requirements.

Additional Information:

• Provider notification requirements are not addressed by this document.

• Ambulance transportation that is done for convenience of the patient is not covered. Please see the Coverage Limitations and Exclusions section below for more information on non-covered ambulance transportation.

Benefit Level for Non-Network Ambulance (Emergency):

If the ambulance transportation is covered, non-network Emergency ambulance (ground, water, or air), is covered at the network level of deductible and coinsurance.

Additional Information:

• For UHIC Choice, Choice+, and Options PPO plans: Non-network Emergency ambulance is covered at a negotiated rate, or, at billed charges if a negotiated rate is not reached.

• For UHIC Non-Differential PPO plans: The benefits for network and non-network are the same level but these plans do not require billed charges to be paid on non-network ambulance.

• For UHIC Plans without a Network (eg, Managed Indemnity): These plans do not have network benefit levels. These plans do not require billed charges to be paid on ambulance services.

Monday, August 15, 2016

Some payment tips in Ambulance billing

Multi-Carrier System (MCS) Guidelines

Payment under the fee schedule for ambulance services:

• Includes a base rate payment plus a payment for mileage;

• Covers both the transport of the beneficiary to the nearest appropriate facility and all items and services associated with such transport; and

• Precludes a separate payment for items and services furnished under the ambulance benefit.

Payment for items and services is included in the fee schedule payment. Such items and services include but are not limited to oxygen, drugs, extra attendants, and EKG testing - but only when such items and services are both medically necessary and covered by Medicare under the ambulance benefit.

30.1.1 - MCS Coding Requirements for Suppliers

The ambulance fee schedule contains the following HCPCS coding logic:

• Seven categories of ground ambulance services;

• Two categories of air ambulance services;

• Payment based on the condition of the beneficiary, not on the type of vehicle used;

• Payment is determined by the point of pickup (as reported by the 5-digit ZIP Code);

• Increased payment for rural services; and

• Services and supplies included in base rate.

Saturday, August 13, 2016

UHC insurance coverage for ambulance service

Emergency Ambulance (Ground, Water, or Air):

Coverage includes Emergency ambulance transportation (including wait time and treatment at the scene) by a licensed ambulance service from the location of the sudden illness or injury, to the nearest hospital where Emergency health services can be performed.
Check enrollee specific benefit document for prior authorization and notification requirements.

The following Emergency ambulance services are covered:

1. Ground ambulance or air ambulance transportation requiring basic life support or advanced life support.

2. Treatment at the scene (paramedic services) without ambulance transportation.

3. Wait time associated with covered ambulance transportation.

4. To a hospital that provides a required higher level of care that was not available at the original hospital.

Air Ambulance:

As a general guideline, when it would take a ground ambulance 30-60 minutes or more to transport an enrollee whose medical condition at the time of pick-up required immediate and rapid transport due to the nature and/or severity of the enrollee’s illness/injury, air transportation may be appropriate.

Air ambulance transportation should meet the following criteria;

1. The patient’s destination is an acute care hospital, and

2. The patient’s condition is such that the ground ambulance (basic or advanced life support) would endanger the enrollee’s life or health, or

3. Inaccessibility to ground ambulance transport or extended length of time required to transport the patient via ground ambulance transportation could endanger the enrollee, or

4. Weather or traffic conditions make ground ambulance transportation impractical, impossible, or overly time consuming.

Refer to #4 (Medicare Benefit Policy Manual) in the References section below.

Additional Information:

• For covered Emergency ambulance, supplies that are needed for advanced life support or basic life support to stabilize a patient’s medical condition are covered under the ambulance benefit.

Non-Emergency Ambulance (Ground or Air) Between Facilities:

Coverage includes non-Emergency ambulance transportation by a licensed ambulance service (either ground or air ambulance), between health care facilities when the ambulance transportation is any of the following:

1. From a non-network hospital to a network hospital

2. To a hospital that provides a required higher level of care that was not available at the original hospital

3. To a more cost-effective acute care facility

4. From an acute facility to a sub-acute setting.

Cost Effective Alternatives (UHIC 2007 COC and 2009 Amendment):

If an alternate method of ambulance transportation is clinically appropriate and more cost effective, we reserve the right to adjust the amount of eligible expenses. As we determine to be appropriate, the coverage determination is based on the enrollee’s medical condition, and geographic location.

Medically Necessary (UHIC 2011 COC):

Non-Emergency ambulance transportation is medically necessary when the patient's condition requires treatment at another facility and when another mode of transportation would endanger the patient’s medical condition. If another mode of transportation could be used safely and effectively, then ambulance transportation is not medically necessary.

Wednesday, August 10, 2016

Modifiers used in Ambualnce billing

General Billing Guidelines

Independent ambulance suppliers may bill on the ASC X12 837 professional claim transaction or the CMS-1500 form. These claims are processed using the Multi-Carrier System (MCS).

nstitution based ambulance providers may bill on the ASC X12 837 institutional claim transaction or Form CMS 1450. These claims are processed using the Fiscal Intermediary Shared System (FISS).

A. Modifiers Specific to Ambulance Service Claims

For ambulance service claims, institutional-based providers and suppliers must report an origin and destination modifier for each ambulance trip provided in HCPCS/Rates. Origin and destination modifiers used for ambulance services are created by combining two alpha characters. Each alpha character, with the exception of “X”, represents an origin code or a destination code. The pair of alpha codes creates one modifier. The first position alpha code equals origin; the second position alpha code equals destination. Origin and destination codes and their descriptions are listed below:

D = Diagnostic or therapeutic site other than P or H when these are used as origin codes;

E = Residential, domiciliary, custodial facility (other than 1819 facility);

G = Hospital based ESRD facility;

H = Hospital;

I = Site of transfer (e.g. airport or helicopter pad) between modes of ambulance transport;

J = Freestanding ESRD facility;

N = Skilled nursing facility;

P = Physician’s office;

R = Residence;

S = Scene of accident or acute event;

X = Intermediate stop at physician’s office on way to hospital (destination code only)

In addition, institutional-based providers must report one of the following modifiers with every HCPCS code to describe whether the service was provided under arrangement or directly:

QM - Ambulance service provided under arrangement by a provider of services; or

QN - Ambulance service furnished directly by a provider of services.

While combinations of these items may duplicate other HCPCS modifiers, when billed with an ambulance transportation code, the reported modifiers can only indicate origin/destination.

Friday, August 5, 2016

Air Ambulance billing basic - CPT cod A0430, A0431

 Air Ambulance

Ambulance Services, section 10.4 – Air Ambulance Services, and section 30.1.2 – Definitions of Air Ambulance Services for additional information on the coverage and definitions of air ambulance services. Under certain circumstances, transportation by airplane or helicopter may qualify as covered ambulance services. If the conditions of coverage are met, payment may be made for the air ambulance services.

Air ambulance services are paid at different rates according to two air ambulance categories:

• AIR ambulance service, conventional air services, transport, one way, fixed wing (FW) (HCPCS code A0430)

• AIR ambulance service, conventional air services, transport, one way, rotary wing (RW) (HCPCS code A0431)

Covered air ambulance mileage services are paid when the appropriate HCPCS code is reported on the claim:

• HCPCS code A0435 identifies FIXED WING AIR MILEAGE

• HCPCS code A0436 identifies ROTARY WING AIR MILEAGE

Effective for claims with dates of service on or after January 1, 2011, air mileage must be reported in fractional numbers of loaded statute miles flown. Contractors must ensure that the appropriate air transport code is used with the appropriate mileage code.

Air ambulance services may be paid only for ambulance services to a hospital. Other destinations e.g., skilled nursing facility, a physician’s office, or a patient’s home may not be paid air ambulance. The destination is identified by the use of an appropriate modifier as defined in Section 30(A) of this chapter.

Claims for air transports may account for all mileage from the point of pickup, including where applicable: ramp to taxiway, taxiway to runway, takeoff run, air miles, roll out upon landing, and taxiing after landing. Additional air mileage may be allowed by the contractor in situations where additional mileage is incurred, due to circumstances beyond the pilot’s control. These circumstances include, but are not limited to, the following:

• Military base and other restricted zones, air-defense zones, and similar FAA restrictions and prohibitions;

• Hazardous weather; or

• Variances in departure patterns and clearance routes required by an air traffic controller.

If the air transport meets the criteria for medical necessity, Medicare pays the actual miles flown for legitimate reasons as determined by the Medicare contractor, once the Medicare beneficiary is loaded onto the air ambulance.

IOM Pub. 100-08, Medicare Program Integrity Manual, chapter 6 – Intermediary MR Guidelines for Specific Services contains instructions for Medical Review of Air Ambulance Services

Contractor Determination of Fee Schedule Amounts

The FS amount is determined by the FS locality, based on the POP of the ZIP Code. Use the ZIP Code of the POP to electronically crosswalk to the appropriate FS amount. All ZIP Codes on the ZIP Code file are urban unless identified as rural by the letter “R” or the letter “B.” Contractors determine the FS amount as follows:

• If an urban ZIP Code is reported with a ground or air HCPCS code, the contractors determine the amount for the service by using the FS amount for the urban base rate. To determine the amount for mileage, multiply the number of reported miles by the urban mileage rate.

• If a rural ZIP Code is reported with a ground HCPCS code, the contractor determines the amount for the service by using the FS amount for the rural base rate. To determine the amount for mileage, contractors must use the following formula:

o For services furnished on or after July 1, 2004, for rural miles 1-17, the rate equals 1.5 times the rural ground mileage rate per mile. Therefore, multiply 1.5 times the rural mileage rate amount on the FS to derive the appropriate FS rate per mile;

o For services furnished during the period July 1, 2004 through December 31, 2008, for all ground miles greater than 50 (i.e., miles 51+), the FS rate equals 1.25 times the applicable mileage rate (urban or rural). Therefore, multiply 1.25 times the urban or rural, as appropriate, mileage rate amount on the FS to derive the appropriate FS rate per mile.

? If a rural ZIP Code is reported with an air HCPCS code, the contractor determines the FS amount for the service by using the FS amount for rural air base rate. To determine the amount allowable for the mileage, multiply the number of loaded miles by the rural air mileage rate.

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