Friday, January 6, 2012

When Medicare covers Ambulance service - Rules and regulation

Ambulance billing - COVERAGE REQUIREMENTS 

Medicare coverage for ambulance transportation is limited by CMS national policy in accordance with federal law. Ambulance services involve the assessment and administration of emergency care by medically trained personnel and transportation of patients within an appropriate, safe and monitored environment.Ambulance transportation is a covered service under Medicare when the patient’s condition is such that the use of any other method of transportation would endanger the patient’s health.

A patient whose condition permits transport in any type of vehicle other than an ambulance would not qualify for services under Medicare.

Medicare payment for ambulance transportation depends on the patient’s condition at the actual time of the transport regardless of the patient’s diagnosis or any other reason for transport.

To be deemed medically necessary for payment, the patient must require both the transportation and the level of service provided.

For the purposes of this policy, the following definitions apply:

  Medically trained personnel refers to individuals who have fulfilled state training and educational requirements and are certified or licensed by their respective state to provide Basic Life Support (BLS) and/or Advanced Life Support (ALS) Emergency Medical Technician (EMT)-level services.
  The vehicle used as an ambulance must be specially designed or equipped to respond to medical emergencies and, in non-emergency situations, be capable of transporting beneficiaries 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.

Medicare Part A and B  - Requirements for Coverage
For ambulance services to be covered by Medicare, the following requirements must be met:

 Actual transportation of the beneficiary occurs. 

Services must be medically necessary and reasonable for the condition of the patient. 

The condition of the patient would not allow transportation by other means. 

A diagnosis must be on the claim or a detailed description of the patient’s condition at the time of transfer must be submitted with the claim or provided upon request to determine medical necessity. 

Ambulance personnel should document their observations of the patient’s condition. 

Transportation to a hospital from another hospital when a patient’s needs cannot be met at the first hospital and the patient is admitted to the second hospital. 

Transportation is to an extended care facility or to the patient’s home. 

Transportation is to the closest appropriate facilities. 

Transportation is provided by an approved supplier/provider of ambulance services. 

The transportation is not part of a Part A (in patient) service.

Medical Necessity

The following conditions may establish that the patient had to be transported by ambulance:

 Patient is transported in an emergency situation; e.g., as a result of an accident or injury.
 Patient needs to be restrained.
 Patient is unconscious or in shock.
 Patient requires oxygen or other emergency treatment on the way to the destination.
 Patient must remain immobile because of a fracture or the possibility of a fracture that has not been set.
 Patient sustains an acute stroke or myocardial infarction.
 Patient is experiencing severe hemorrhaging.
 Patient has a condition that requires him to be moved only by stretcher.
 Patient has a condition that makes him bed-confined before and after the ambulance trip.

Definition of Bed-Confined

There is now a national definition of the term “bed-confined.” The patient must meet all of the following criteria
 Unable to get up from bed without assistance.
 Unable to ambulate.
 Unable to sit in a chair or wheelchair.

Note: The term “bed-confined” is not synonymous with “bed rest” or “non-ambulatory.” In addition, “bed-confined” is not meant to be the sole criterion to be used in determining if the patient must be transported by ambulance. It is one factor to be considered when making coverage determinations.

Member Pre-Service Notification Requirements for Non-Emergency Ambulance

* If UHIC initiates the non-Emergency ambulance transportation, member notification is not required.

* If UHIC does not initiate the non-Emergency ambulance transportation, certain plans may require the member or the provider to call in for notification. Please see the member specific benefit plan document 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 (e.g., Managed Indemnity): These plans do not have network benefit levels. These plans do not require billed charges to be paid on ambulance services.

Coverage Limitations and Exclusions

The following services are not eligible for coverage:

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

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

* 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.

* 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 member’s health are not covered.

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

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

* Ambulance transportation for patient convenience or other miscellaneous reasons for patient and/or family.

* Examples include but are not limited to:

o Patient wants to be at a certain hospital or facility for personal/preference reasons,

o 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),

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

o Patient is deceased (i.e., transportation to the coroner’s office or mortuary)

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

o Hospital to home

o Home to physician’s office

o Home (e.g., 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.

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