Friday, June 10, 2016

What situation ambulance service would be covered and not covered

When Ambulance and Medical Transport Services are covered

1. Ground emergency ambulance service for the transport of a patient is considered medically necessary when all the following criteria are met:

a. The ambulance must be equipped with appropriate emergency and medical supplies and equipment;

b. The patient’s condition must be such that any other form of transportation would be medically contraindicated;

c. The patient must be transported to the nearest hospital with the appropriate facilities for the treatment of the patient’s illness or injury.

2. Non-emergency medical transport services for the transport of a hospital inpatient to another facility for specialized services are considered eligible for coverage when all of the following criteria are met:

a. The patient is a registered inpatient in an acute care hospital;

b. The specialized services are not available in the hospital in which the patient is registered Ambulance and Medical Transport Services  and those specialized services are considered reasonable, medically necessary, and covered under the members benefit plan;

c. The provider of the specialized services is the nearest one with the required capabilities.


3. Air or Sea Ambulance services may be medically necessary in exceptional circumstances. All of the criteria pertaining to ground transportation must be met, as well as one of the following additional conditions:

a. The patient’s medical condition must require immediate and rapid ambulance transport to the nearest appropriate medical facility that could not have been provided by land ambulance;

b. The point of pick-up is inaccessible by land vehicle;

c. Great distances, limited time frames, or other obstacles are involved in getting the patient to the nearest hospital with appropriate facilities for treatment;

d. The patient’s condition is such that the time needed to transport a patient by land to the nearest appropriate medical facility poses a threat to the patient’s health.


4. Ambulance or medical transport services are considered eligible for coverage if the patient is legally pronounced dead after the ambulance was called, but before pickup, or enroute to the hospital.


5. Transportation from a hospital, skilled nursing facility or rehabilitation facility to a patient’s residence when the patient’s condition requires skilled monitoring during transport with the services of an EMT attendant or other licensed healthcare practitioner.


When Ambulance and Medical Transport Services are not covered

1. When the medical guidelines shown above are not met:

2. If the patient is legally pronounced dead before the ambulance is called, the services are not considered medically necessary.

3. Transportation provided primarily for the convenience of the patient, patient’s family or physician is not covered.

4. Transportation for the purpose of receiving a service considered NOT medically necessary is also considered NOT medically necessary, even if the destination is an appropriate facility.

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