Tuesday, August 30, 2016

CMS Supplied National ZIP Code File and National Ambulance Fee Schedule File

CMS will provide each contractor with two files: a national ZIP Code file and a national Ambulance FS file.

A. The national ZIP5 Code file is a file of 5-digit USPS ZIP Codes that will map each ZIP Code to the appropriate FS locality. Every 2 months, CMS obtains an updated listing of ZIP Codes from the USPS. On the basis of the updated USPS file, CMS updates the Medicare ZIP Code file and makes it available to contractors.

The following is a record layout of the ZIP5 file effective January 1, 2009


Field Name           Position         Format         COBOL Description

State                 1-2               X(02)        Alpha State Code

ZIP Code             3-7          X(05)                 Postal ZIP Code

Carrier                     8-12          X(05)           Medicare Part B Carrier Number

Pricing Locality       13-14             X(02)              Pricing Locality

Rural Indicator             15               X(01)                  Effective 1/1/07 Blank = urban,                                                                                                                                         R =rural, B=super rural

Beneficiary Lab CB Locality         16-17             X(02)                 Lab competitive bid locality;
                          Z1= CBA1
                                    Z2= CBA2
                  Z9= Not a demonstration locality

Rural Indicator 2        18                   X(01)               What was effective 12/1/06 Blank=urban, R=rural,                                                                                                                                    B =super rural

Filler                19-20              X(02)

Plus Four Flag                  21              X(01)              0 = no +4 extension
                                                                 1 = +4 extension

Filler                22-75           X(54)      

Year/Quarter              76-80           X(05)                YYYYQ

NOTE: Effective October 1, 2007, claims for ambulance services will continue to be submitted and priced using 5-digit ZIP Codes. Contractors will not need to make use of the ZIP9 file for ambulance claims.

Beginning in 2009, contractors shall maintain separate ZIP Code files for each year which will be updated on a quarterly basis. Claims shall be processed using the correct ZIP Code file based on the date of service submitted on the claim.

A ZIP Code located in a rural area will be identified with either a letter “R” or a letter “B.” Some ZIP Codes will be designated as rural due to the Rural Urban Commuting Area (RUCA) Score even though the ZIP Code may be located, in whole or in part, within an MSA or Core Based Statistical Area (CBSA).

A“B” designation indicates that the ZIP Code is in a rural county (or RUCA area) that is comprised by the lowest quartile by population of all such rural areas arrayed by population density. Effective for claims with dates of service between July 1, 2004 and December 31, 2010, contractors must apply a bonus amount to be determined by CMS to the base rate portion of the payment under the FS for ground ambulance services with a POP “B” ZIP Code. This amount is in addition to the rural bonus amount applied to ground mileage for ground transports originating in a rural POP ZIP Code.

Each calendar quarter beginning October 2007, CMS will upload updated ZIP5 and ZIP9 ZIP Code files to the Direct Connect (formerly the Network Data Mover). Contractors shall make use of the ZIP5 file for ambulance claims and the ZIP9 file as appropriate per IOM Pub. 100-04, Medicare Claims Processing Manual, chapter 1 –General Billing Requirements , section - Payment Jurisdiction Among Local Carriers for Services Paid Under the Physician Fee Schedule and Anesthesia Services and the additional information found in Transmittal 1193, Change Request 5208, issued March 9, 2007. The updated files will be available for downloading on approximately November 15th for the January 1 release, approximately February 15th for the April 1 release, approximately May 15th for the July 1 release, and approximately August 15th for the October 1 release.

1. Upon quarterly Change Requests communicating the availability of updated ZIP Code files, go to the Direct Connect and search for the files. Confirm that the release number (last 5 digits) corresponds to the upcoming calendar quarter. If the release number (last 5 digits) does not correspond to the upcoming calendar quarter, notify CMS.

2. After confirming that the ZIP Code files on the Direct Connect corresponds to the next calendar quarter, download the files and incorporate the files into your testing regime for the upcoming model release.

The names of the files will be in the following format: MU00.AAA2390.ZIP5.LOCALITY.Vyyyyr and MU00.AAA2390.ZIP9.LOCALITY.Vyyyyr where “yyyy” equals the calendar year and “r” equals the release number with January =1, April =2, July =3, and October =4. So, for example, the names of the file updates for October 2007 are MU00.AAA2390.ZIP5.LOCALITY.V20074 and MU00.AAA2390.ZIP9.LOCALITY.V20074. The release number for this file is 20074, release 4 for the year 2007.

When the updated files are loaded to the Direct Connect, they will overlay the previous ZIP Code files.

Friday, August 26, 2016

Payment Guideline for multiple ambulance usage

Jurisdiction of the claim is based on whether only one ambulance vehicle or multiple vehicles were used.

A. One Ambulance Vehicle Used

If only one vehicle is used to transport the patient from the point of initial pickup to the final destination, jurisdiction is with the carrier serving the point of origin, i.e., home station of the vehicle. This carrier has qualification information on the ambulance supplier and in most cases all other pertinent details necessary to adjudicate a claim.

EXAMPLE: A patient is picked up at the Johns Hopkins Hospital in Baltimore, Maryland and transported to his home in West Virginia by an ambulance dispatched from the area of the patient’s home. The carrier serving the point of origin of the ambulance, Nationwide Mutual Insurance Company, Part B carrier for the State of West Virginia, has jurisdiction of any claim filed. In this case Nationwide should have all the data necessary to make proper payment, i.e., certification of the ambulance company, price information and data pertaining to the nearest appropriate company, price information and data pertaining to the nearest appropriate facility. Had an ambulance whose home station was in Baltimore been used, the carrier servicing Baltimore, Maryland would have had jurisdiction. The Baltimore carrier would then have had
to obtain data concerning the nearest appropriate facility to the patient’s home from Nationwide

B. More Than One Vehicle Used

If more than one vehicle is used in transporting the patient to their destination, jurisdiction of the claim lies with:

• The carrier serving the home base of the ambulance taking the patient on the first leg of the trip, on a trip to a distant institution more remote than the nearest appropriate facility; or

• The carrier serving the home base of the ambulance taking the patient on the final leg of the trip home, on a trip from an institution more remote than the nearest appropriate facility.

• If there is no claim for the final leg of the trip, the carrier serving the patient’s home area handles any resulting claims or disallowance actions.

EXAMPLE: A patient is transported by ambulance from a hospital in Miami Beach, Florida to Miami International Airport and from there by air ambulance to LaGuardia Airport in Queens, New York City. At the airport he is picked up by an ambulance (based in Yonkers, New York) and taken to his home in Yonkers, New York. The carrier that handles the adjudication is the carrier whose area of responsibility includes Yonkers, New York, since partial reimbursement is based upon the nearest appropriate facility to his residence when he is being returned home from a distant institution.

In rules A and B above, the principle followed is that the carrier having the information to determine the “nearest appropriate facility” is the one to adjudicate the claim. In any event, before any partial reimbursement can be made, the carriers as designated in rules A and B, must have all the information concerning the patient’s transportation, from initial pickup to final destination.

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.

Popular Posts