Monday, October 26, 2015

Coverage Guidelines for Ambulance Service Claims



Payment may be made for expenses incurred by a patient for ambulance service provided conditions l, 2, and 3 in the left-hand column have been met. The right-hand column indicates the documentation needed to establish that the condition has been met. 

Conditions  Review Action
1. Patient was transported by an approved supplier of ambulance services. 1. Ambulance suppliers are explained in greater detail
2. The patient was suffering from an illness or injury, which contraindicated transportation by other means. 2. (a) The contractor presumes the requirement was met if the submitted documentation indicates that the patient:                                                    • Was transported in an emergency situation, e.g., as a result of an accident, injury or acute illness, or                           • Needed to be restrained to prevent injury to the beneficiary or others; or                                       • Was unconscious or in shock; or                                                • Required oxygen or other emergency treatment during transport to the nearest appropriate facility; or                                                                        • Exhibits signs and symptoms of acute respiratory distress or cardiac distress such as shortness of breath or chest pain; or
• Exhibits signs and symptoms that indicate the possibility of acute stroke; or
• Had to remain immobile because of a fracture that had not been set or the possibility of a fracture; or
• Was experiencing severe hemorrhage; or
• Could be moved only by stretcher; or
• Was bed-confined before and after the ambulance trip
(b) In the absence of any of the conditions listed in (a) above additional documentation should be obtained to establish medical need where the evidence indicates the existence of the circumstances listed below:
(i) Patient’s condition would not ordinarily require movement by stretcher, or
(ii) The individual was not admitted as a hospital inpatient (except in accident cases), or
(iii) The ambulance was used solely because other means of transportation were unavailable, or
(iv) The individual merely needed assistance in getting from his room or home to a vehicle.
(c) Where the information indicates a situation not listed in 2(a) or 2(b) above, refer the case to your supervisor.
3. The patient was transported from and to points listed below. 3. Claims should show the ZIP Code of the point of pickup.
(a) From patient’s residence (or other place where need arose) to hospital or skilled nursing facility. (a) i. Condition met if trip began within the institution’s service area as shown in the carrier’s locality guide. ii. Condition met where the trip began outside the institution’s service area if the institution was the nearest one with appropriate facilities.
(b) Skilled nursing facility to a hospital or hospital to a skilled nursing facility. (i) Condition met if the ZIP Code of the pickup point is within the service area of the destination as shown in the carrier’s locality guide.
(ii) Condition met where the ZIP Code of the pickup point is outside the service area of the destination if the destination institution was the nearest appropriate facility.
(c) Hospital to hospital or skilled nursing facility to skilled nursing facility. (c) Condition met if the discharging institution was not an appropriate facility and the admitting institution was the nearest appropriate facility.
(d) From a hospital or skilled
nursing facility to patient’s
residence.
(d)
(i) Condition met if patient’s residence is within the
institution’s service area as shown in the carrier’s locality guide.
(ii) Condition met where the patient’s residence is outside the institution’s service area if the institution was the nearest appropriate facility.
(e) Round trip for hospital or
participating skilled nursing
facility inpatients to the
nearest hospital or
nonhospital treatment
facility.
(e) Condition met if the reasonable and necessary
diagnostic or therapeutic service required by patient’s condition is not available at the institution where the beneficiary is an inpatient.
4. Ambulance services involving hospital admissions in Canada or Mexico are covered if the following conditions are met: 4. (a) The foreign hospitalization has been determined to be covered; and
(b) The ambulance service meets the coverage
requirements set forth. If the foreign
hospitalization has been determined to be covered on the basis of emergency services, the necessity requirement and the destination requirement are
considered met.
5. The carrier will make partial
payment for otherwise covered ambulance service, which
exceeded limits defined in item
5 & 6 (a) From the pickup point to the nearest
appropriate facility, or
6. The carrier will base the
payment on the amount
payable had the patient been
transported:
5 & 6 (b) From the nearest appropriate facility to the beneficiary’s residence where he or she is being returned home from a distant institution.


NOTE: A patient’s residence is the place where he or she makes his/her home and dwells permanently, or for an extended period of time. A skilled nursing facility is one, which is listed in the Directory of Medical Facilities as a participating SNF or as an institution which meets §1861(j)(1) of the Act.

NOTE: A claim for ambulance service to a participating hospital or skilled nursing facility should not be denied on the grounds that there is a nearer nonparticipating institution having appropriate facilities.

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