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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules say that plans must pay for ambulance services when an emergency exists or when other means of
transport would endanger the patient's health. An emergency is defined as when a prudent layperson would
believe that without immediate medical attention there would be serious jeopardy to his or her health. You can
find these rules in the Medicare Managed Care Manual, Chapter 4, Sections 20.1 and 20.2.
If both the origin and destination of the ambulance transport are providers, e.g., a hospital, critical access
hospital (CAH), skilled nursing facility (SNF), then responsibility for payment for the ambulance transport is
determined in accordance with the following sequential criteria.
NOTE: These criteria must be applied in sequence as a flow chart and not independently of one another.
1. Provider Numbers:
If the Medicare-assigned provider numbers of the two providers are different, then the ambulance service is
separately billable to the program. If the provider number of both providers is the same, then consider criterion
2, "campus".
2. Campus:
Following criterion 1, if the campuses of the two providers (sharing the same provider numbers) are the same,
then the transport is not separately billable to the program. In this case the provider is responsible for payment.
If the campuses of the two providers are different, then consider criterion 3, "patient status." "Campus" means
the physical area immediately adjacent to the provider's main buildings, other areas and structures that are not
strictly contiguous to the main buildings, but are located within 250 yards of the main buildings, and any of the
other areas determined on an individual case basis by the CMS regional office to be part of the provider's
campus.
3. Patient Status: Inpatient vs. Outpatient
Following criteria 1 and 2, if the patient is an inpatient at both providers (i.e., inpatient status both at the origin
and at the destination, providers sharing the same provider number but located on different campuses), then the
transport is not separately billable. In this case the provider is responsible for payment. All other combinations
(i.e., outpatient-to-inpatient, inpatient-to-outpatient, outpatient-to-outpatient) are separately billable to the
program.
The transfer, i.e., the discharge of a beneficiary from one provider with a subsequent admission to another
provider, is also payable as a Part B ambulance transport, provided all program coverage criteria are met,
because, at the time that the beneficiary is in transit, the beneficiary is not a patient of either provider and not
subject to either the inpatient preadmission payment window or outpatient payment packaging requirements.
This includes an outpatient transfer from a remote, off-campus emergency department (ER) to becoming an
inpatient or outpatient at the main campus hospital, even if the ER is owned and operated by the hospital.
You can find this information in Medicare Benefit Policy Manual Chapter 10 - Ambulance Services.
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.