Saturday, August 20, 2016

What are situation ambulance service will not be paid ?

Coverage Limitations and Exclusions

The following services are not eligible for coverage:

1. Ambulance services from providers that are not properly licensed to be performing the ambulance services rendered.

2. Air ambulance that does not meet the covered indications in the Air Ambulance criteria listed above.

3. Non-ambulance transportation. Non-ambulance transportation is not covered even if rendered in an Emergency situation. Examples include but are not limited to commercial or private airline or helicopter, a police car ride to a hospital, medi-van transportation, wheel-chair van, taxi ride, bus ride, etc.

4. Ambulance transportation when other mode of transportation is appropriate. Except as indicated under the Indications for Coverage section of this policy, ambulance services when transportation by other means would not endanger the enrollee’s health, are not covered.

5. Ambulance transportation to a home, residential, domiciliary or custodial facility is not covered.

6. Ambulance transportation that violates the notification criteria listed in the Indications for Coverage section above.

7. Ambulance transportation for patient convenience or other miscellaneous reasons for patient and/or family. Examples include but are not limited to:

a. Patient wants to be at a certain hospital or facility for personal/preference reasons;

b. Patient is in foreign country, or out of state, wants to come home to for a surgical procedure or treatment (this includes those recently discharged from inpatient care);

c. Patient is going to a routine service and is medically able to use another mode of transportation but can’t find it;

d. Patient is deceased (ie, transportation to the coroner’s office or mortuary)

8. Ambulance transportation deemed not appropriate. Examples include but are not limited to:

a. Hospital to home

b. Home to physician’s office

c. Home (eg. residence, nursing home, domiciliary or custodial facility) to a hospital for a scheduled service

Additional Information:

• If the patient is at a Skilled Nursing Facility/Inpatient Rehabilitation Facility and has met the annual day/visit limit on Skilled Nursing Facility/Inpatient Rehabilitation Facility Services, ambulance transports (during the non-covered days) are not eligible.

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