(Medicare Benefit Policy Manual)

10.4.3 - Time Needed for Ground Transport  (Rev. 1, 10- 01-03) A3-3114.C.11.C, B3- 2120.4.C   Differing Statewide Emergency Medical Services (EMS) systems determine the amount  and level of basic and advanced life support ground transportation available.  However, there are very limited emergency cases where ground transportation is available but the time required to transport the patient by ground as opposed to air endangers the beneficiarys life or health.  As a general guideline, when it would take a ground ambulance 30 -60 minutes or more to transport a beneficiary whose medical condition at the time of pick -up required immediate and rapid transport due to the nature and/or severity of the beneficiarys illness/injury, A/B MACs (A) and (B) should consider air transportation to be appropriate.   10.4.4 - Hospital to Hospital Transport  (Rev. 1, 10- 01-03) A3-3114.C.11.E, B3- 2120.4.E   Air ambulance transport is covered for transfer  of a patient from one hospital to another if the medical appropriateness criteria are met, that is, transportation by ground ambulance would endanger the beneficiarys health and the transferring hospital does not have adequate facilities to provide the m edical services needed by the patient.  Examples of such specialized medical services that are generally not available at all type of facilities may include but are not limited to: burn care, cardiac care, trauma care, and critical care.  A patient transported from one hospital to another hospital is covered only if the hospital to which the patient is transferred is the nearest one with appropriate facilities.  Coverage is not available for transport from a hospital capable of treating the patient because the patient and/or the patients family prefer a specific hospital or physician.   10.4.5 - Special Coverage Rule  (Rev. 1, 10- 01-03) A3-3114.C.11.F, B3- 2120.4.F   Air ambulance services are not covered for transport to a facility that is not an acute care hospital, such as a nursing facility, physicians office, or a beneficiarys home.   10.4.6 - Special Payment Limitations  (Rev. 133, Issued: 10- 22-10, Effective: 01- 01-11, Implementation: 01- 03-11)  If a determination is made to order transport by air ambulance, but ground ambulance transport would have sufficed, payment for the air ambulance transport is based on the amount payable for ground ambulance transport.   If the air transport was medically appropriate (that is, ground transportation was contraindicat ed, and the beneficiary required air transport to a hospital), but the beneficiary could have been treated at a hospital nearer than the one to which they were transported, the air transport payment is limited to the rate for the distance from the point of pickup to that nearer hospital.  10.4.7 - Documentation  (Rev. 103; Issued:  02- 20-09; Effective Date:  01 -05-09; Implementation Date:  03 -20-09)  In order to determine the medical appropriateness of air ambulance services the A/B MAC (A) or (B) may request that documentation be submitted that indicates the air ambulance services are reasonable and necessary to treat the beneficiarys life-threatening condition. The contractors medical staff may consider reviewing all claims for air ambulance service s.  10.4.8 - Air Ambulance Transports Canceled Due to Weather or Other Circumstances Beyond the Pilots Control  (Rev. 1, 10- 01-03)  The chart below shows the Medicare payment determination for various air ambulance scenarios in which the flight is aborted due to bad weather, or other circumstance beyond the pilots control.  Air Ambulance Scenarios:  Aborted Flights  Aborted Flight Scenario  Medicare Payment Determination  Any time before the beneficiary is loaded onboard (i.e., prior to or after take -off to  point -of-pickup.)  None.  Transport after the beneficiary is loaded onboard.  Appropriate air base rate, mileage, and rural adjustment.   10.4.9 - Effect of Beneficiary Death on Program Payment for Air Ambulance Transports  (Rev. 103; Issued:  02- 20-09; Effe ctive Date:  01 -05-09; Implementation Date:  03 -20-09)  Because the Medicare ambulance benefit is a transport benefit, if no transport of a Medicare beneficiary occurs, then there is no Medicare -covered service.  In general, if the beneficiary dies before being transported, then no Medicare payment may be made.  Thus, in a situation where the beneficiary dies, whether any payment under the Medicare ambulance benefit may be made depends on the time at which the beneficiary is pronounced dead by an individual  authorized by the State to make such pronouncements.   The chart below shows the Medicare payment determination for various air ambulance scenarios in which the beneficiary dies.  In each case, the assumption is that the ambulance transport would have othe rwise been medically necessary. If the flight is aborted for other reasons, such as bad weather, the Medicare payment determination is based on whether the beneficiary was onboard the air ambulance.    Air Ambulance Scenarios:  Beneficiary Death  Time of Death Pronouncement  Medicare Payment Determination  Prior to takeoff to point -of-pickup with notice to dispatcher and time to abort the flight. None. NOTE:  This scenario includes situations in which the air ambulance has taxied to the runway, and/or has been cleared for takeoff, but has not actually taken off.) After takeoff to point -of-pickup, but before the beneficiary is loaded.  Appropriate air base rate with no mileage or rural adjustment; use the QL modifier when submitting the claim.  After the beneficiary is loaded onboard, but prior to or upon arrival at the receiving facility.  As if the beneficiary had not died.  10.5 - Joint Responses (Rev. 125, Issued 05- 14-10, Effective: 01- 04-10, Implementation: 06- 15-10)  A. BLS/ALS Joint Responses   In situations where a BLS entity provides the transport of the beneficiary and an ALS entity provides a service that meets the fee schedule definition of an ALS intervention (e.g., ALS assessment, Paramedic Intercept services, etc.), the BLS supplier may bill  Medicare the ALS rate provided that a written agreement between the BLS and ALS entities exists prior to submitting the Medicare claim.  Providers/suppliers must provide a copy of the agreement or other such evidence (e.g., signed attestation) as determin ed by  their A/B MAC (A) or (B) upon request.   A/B MACs (A) and (B) must refer any issues that cannot be resolved to the regional office.   Medicare does not regulate the compensation between the BLS entity and the ALS entity.  If there is no agreement between the BLS ambulance supplier and the ALS entity furnishing the service, then only the BLS level of payment may be made.  In this situation, the ALS entitys services are not covered, and the beneficiary is liable for the expense of the ALS services to the extent that these services are beyond the scope of the BLS level of payment.  B. Ground to Air Ambulance Transports   When a beneficiary is transported by ground ambulance and transferred to an air ambulance, the ground ambulance may bill Medicare for the level of service provided and mileage from the point of pickup to the point of transfer to the air ambulance.  20 - Coverage Guidelines for Ambulance Service Claims  (Rev. 103; Issued:  02- 20-09; Effective Date:  01 -05-09; Implementation Date:  03 -20-09)   Payment may be made for expenses incurred by a patient for ambulance service provided conditions l, 2, and 3 in the left-hand column have been met.  The right-hand column indicates the documentation needed to establish that the condition has been met.  Cond itions  Review Action  1. Patient was transported by an approved supplier of ambulance services.  1. Ambulance suppliers are explained in greater detail in 10.1.3