Saturday, August 13, 2016

UHC insurance coverage for ambulance service

Emergency Ambulance (Ground, Water, or Air):

Coverage includes Emergency ambulance transportation (including wait time and treatment at the scene) by a licensed ambulance service from the location of the sudden illness or injury, to the nearest hospital where Emergency health services can be performed.
Check enrollee specific benefit document for prior authorization and notification requirements.

The following Emergency ambulance services are covered:

1. Ground ambulance or air ambulance transportation requiring basic life support or advanced life support.

2. Treatment at the scene (paramedic services) without ambulance transportation.

3. Wait time associated with covered ambulance transportation.

4. To a hospital that provides a required higher level of care that was not available at the original hospital.

Air Ambulance:

As a general guideline, when it would take a ground ambulance 30-60 minutes or more to transport an enrollee whose medical condition at the time of pick-up required immediate and rapid transport due to the nature and/or severity of the enrollee’s illness/injury, air transportation may be appropriate.

Air ambulance transportation should meet the following criteria;

1. The patient’s destination is an acute care hospital, and

2. The patient’s condition is such that the ground ambulance (basic or advanced life support) would endanger the enrollee’s life or health, or

3. Inaccessibility to ground ambulance transport or extended length of time required to transport the patient via ground ambulance transportation could endanger the enrollee, or

4. Weather or traffic conditions make ground ambulance transportation impractical, impossible, or overly time consuming.

Refer to #4 (Medicare Benefit Policy Manual) in the References section below.

Additional Information:

• For covered Emergency ambulance, supplies that are needed for advanced life support or basic life support to stabilize a patient’s medical condition are covered under the ambulance benefit.

Non-Emergency Ambulance (Ground or Air) Between Facilities:

Coverage includes non-Emergency ambulance transportation by a licensed ambulance service (either ground or air ambulance), between health care facilities when the ambulance transportation is any of the following:

1. From a non-network hospital to a network hospital

2. To a hospital that provides a required higher level of care that was not available at the original hospital

3. To a more cost-effective acute care facility

4. From an acute facility to a sub-acute setting.

Cost Effective Alternatives (UHIC 2007 COC and 2009 Amendment):

If an alternate method of ambulance transportation is clinically appropriate and more cost effective, we reserve the right to adjust the amount of eligible expenses. As we determine to be appropriate, the coverage determination is based on the enrollee’s medical condition, and geographic location.

Medically Necessary (UHIC 2011 COC):

Non-Emergency ambulance transportation is medically necessary when the patient's condition requires treatment at another facility and when another mode of transportation would endanger the patient’s medical condition. If another mode of transportation could be used safely and effectively, then ambulance transportation is not medically necessary.

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