Wednesday, July 8, 2015

Ambulance Services Furnished by Providers of Services


The Part A intermediary is responsible for the processing of claims for ambulance service furnished under arrangements by participating hospitals, skilled nursing facilities, and home health agencies. Since provider ambulance services furnished “under arrangements” with suppliers can be covered only if the supplier meets the above requirements, the Part A intermediary may ask the carrier to identify those suppliers who meet the requirements. Where the "under arrangement" supplier also supplies ambulance services directly to Medicare beneficiaries, i.e., services that are not pursuant to an arrangement with a provider, the intermediary contacts the Part B carrier to ascertain whether it has already determined whether the crew and ambulance requirements are met.

In such a situation, the intermediary should accept the carrier’s determination without
pursuing its own investigation.

Equipment and Supplies

As mentioned above, the ambulance must have customary patient care equipment and
first aid supplies, including reusable devices and equipment such as backboards,
neck boards, and inflatable leg and arm splints. These are all considered part of the
general ambulance service and payment for them is included in the payment rate for the
transport.

Necessity and Reasonableness

To be covered, ambulance services must be medically necessary and reasonable.

Necessity for the Service

Medical necessity is established when the patient's condition is such that use of any other method of transportation is contraindicated. In any case in which some means of transportation other than an ambulance could be used without endangering the individual's health, whether or not such other transportation is actually available, no payment may be made for ambulance services. In all cases, the appropriate documentation must be kept on file and, upon request, presented to the carrier/intermediary. It is important to note that the presence (or absence) of a physician’s order for a transport by ambulance does not necessarily prove (or disprove) whether the transport was medically necessary. The ambulance service must meet all program coverage criteria in order for payment to be made.
In addition, the reason for the ambulance transport must be medically necessary. That is, the transport must be to obtain a Medicare covered service, or to return from such a service.

Reasonableness of the Ambulance Trip
Under the FS payment is made according to the level of medically necessary services actually furnished. That is, payment is based on the level of service furnished (provided they were medically necessary), not simply on the vehicle used. Even if a local government requires an ALS response for all calls, payment under the FS is made only for the level of service furnished, and then only when the service is medically necessary.

Medicare Policy Concerning Bed-Confinement
As stated above, medical necessity is established when the patient’s condition is such that the use of any other method of transportation is contraindicated. Contractors may presume this requirement is met under certain circumstances, including when the beneficiary was bed-confined before and after the ambulance trip.

A beneficiary is bed-confined if he/she is:
• Unable to get up from bed without assistance;
• Unable to ambulate; and
• Unable to sit in a chair or wheelchair.
The term "bed confined" is not synonymous with "bed rest" or "nonambulatory". Bedconfinement, by itself, is neither sufficient nor is it necessary to determine the coverage for Medicare ambulance benefits. It is simply one element of the beneficiary's condition that may be taken into account in the intermediary's/carrier's determination of whether means of transport other than an ambulance were contraindicated.


Documentation Requirements
In all cases, the appropriate documentation must be kept on file and, upon request, presented to the carrier. It is important to note that neither the presence nor absence of a signed physician’s order for an ambulance transport necessarily proves (or disproves) whether the transport was medically necessary. The ambulance service must meet all program coverage criteria in order for payment to be made.

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