Tuesday, November 7, 2017

Out of state ambulance transport billing guide


Except for emergencies, out of state, nonborderland transports require PA. (Refer to the General Information for Providers chapter of this manual for additional information.) The ambulance provider, home health agency (HHA), hospital, NF, physician, or social worker may request this authorization. The ambulance provider must retain documentation of medical necessity (physician's order) in the beneficiary's file to support the need for ambulance transportation. To request
authorization, the requestor must call or write the MDHHS Program Review Division before services are rendered. (Refer to the Directory Appendix for contact information.) The request must include:

* Point of pick-up

* Beneficiary's name and Medicaid ID number

* Diagnosis

* Service to be provided

* Destination point

* Reason why the ambulance transport was medically necessary

* Reason why the beneficiary cannot be transported by any other means

* Name and address of the ambulance provider

* Requestor's name

Based on the authorization requested, MDHHS approves or denies the request. The ambulance provider may render the service upon receipt of verbal approval. A copy of the approval authorization letter is mailed to the ambulance provider following the verbal authorization. The ambulance provider may not bill Medicaid until he has received the authorization letter. The ambulance provider must keep a copy of the authorization letter in the beneficiary's file.

The requestor must notify the MDHHS Program Review Division of any changes to the approved PA (e.g., change in service date or ambulance provider, etc.).

When seeking reimbursement for out of state transports, the PA number must be entered on the claim, except in the case of emergency transports.


Circumstances under which Medicaid does not pay for ambulance transportation include, but are not limited to:

* Medi-car, Medi-van, or wheelchair transports.

* Transport to a funeral home.

* Trips made for services, such as drawing blood and catheterization that could have been provided at the beneficiary’s

* Transportation of a beneficiary pronounced dead before the ambulance was called.

* Round trips when a beneficiary is taken from a hospital to another facility and returned to the same hospital. As long as the beneficiary is an inpatient, all ancillary services are the responsibility of the hospital.

* Transport of correctional facility inmates to and from the correctional facility.

* Transports that are not medically necessary.


Rates of reimbursement paid to out-of-state hospitals and free-standing diagnostic and treatment centers for most outpatient services provided to New York’s Medicaid beneficiaries will be based on New York’s Ambulatory Patient Groups (APG) payment system. Out-of-state providers have been issued new rate codes by the State fiscal agent to enable billing for hospital outpatient, emergency department, and ambulatory surgery unit services, as well as for services provided by free-standing clinics and ambulatory surgery centers. Effective immediately, rates of payment for out-of-state providers will follow these rules:

** Rates of payment for out-of-state providers in counties contiguous to New York City and New York’s Dutchess, Putnam, Westchester, Rockland and Orange Counties will reflect the average APG payment for the same services applicable to New York State providers in those downstate areas. Out-of-state counties contiguous to the downstate rate region include: Sussex, Passaic, Bergin, Hudson, Essex, Middlesex, Union and Monmouth Counties in New Jersey; Pike County in Pennsylvania; and Litchfield and Fairfield Counties in Connecticut.

** Rates of payment for all other out-of-state providers will reflect the average APG payment for the same services applicable to providers in upstate New York.

** Out-of-state providers must bill using the appropriate APG rate code. Please view the chart below:

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