Sunday, March 20, 2016

Nearest Appropriate hospital - Ambulance benifit limitation


Missouri Statute 208.152 authorizes MO HealthNet coverage of emergency ambulance services. Only those transports considered an emergency and made to the nearest appropriate hospital are covered and should be submitted to MO HealthNet for payment. This policy can be found in section 13.3.A of the MO HealthNet Ambulance manual located at Exceptions to this policy can be found in sections 13.3.P, Healthy Children and Youth (HCY) services; 13.3.O, transfer of participants to another hospital; and 13.3.L, transports for specialized testing.

Emergency services are services required when there is a sudden or unforeseen situation or occurrence or a sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that the absence of immediate medical attention could reasonably be expected to result in:

• placing the participant’s health in serious jeopardy; or

• serious impairment to bodily functions; or

• serious dysfunction of any bodily organ or part.

“Nearest appropriate hospital” is the hospital equipped and staffed to provide the needed care for the illness or injury involved. It is the institution, its equipment, its personnel and its capability to provide the service necessary to support the required medical care that determines whether it has appropriate facilities. The fact a more distant institution is better equipped, either qualitatively or quantitatively, to care for the participant does not in itself support a conclusion a closer institution does not have appropriate facilities. MO HealthNet does not allow transportation to a more distant facility solely to avail a participant of the services of a specific physician or family or personal preferences when considering the “nearest appropriate facility”.

Services not considered emergent or within the exempted categories should not be submitted to MO HealthNet for processing. Non-emergent trips, as well as services provided to a participant not eligible for MO HealthNet benefits on the date of the transport, may be billed to the participant. MO HealthNet participants who dispute a bill from an ambulance provider may contact the MO HealthNet Participant Services Unit (PSU) at 1-800-392-2161. It is not the responsibility of the ambulance provider to submit a claim to MO HealthNet in order to receive a denial before billing the participant.

If the participant contacts PSU regarding a bill, the ambulance provider may be contacted by PSU staff requesting a copy of the trip ticket. This documentation must be sent to PSU by the requested date in their letter. A medical consultant reviews the trip ticket to determine if the trip was emergent in nature. After review both the ambulance provider and the participant will receive written  otification. If the review determines the transport meets the emergency criteria, the provider will be instructed to submit the claim to MO HealthNet and the participant is not financially responsible. If the review determines the transport does not meet policy, the participant is notified they are responsible for payment of the bill. If the ambulance provider does not comply with PSU’s request for documentation, the participant is notified they are not responsible for payment of the bill.

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