(Medicare Benefit Policy Manual)

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 2. The patient was suffering from an illness or injury, which contraindicated transportation by other means. ( 10.2) 2. (a) The A/B MAC (A) or (B) presumes the requirement was met if the submitted documentation indicates that the patient:   Was transported in an emergency situatio n, e.g., as a result of an accident, injury or acute illness, or  Needed to be restrained to prevent injury to the beneficiary or others; or  Was unconscious or in shock; or  Required oxygen or other emergency treatment during transport to the nearest appropr iate facility; or  Exhibits signs and symptoms of acute respiratory distress or cardiac distress such as shortness of breath or chest pain; or  Exhibits signs and symptoms that indicate the possibility of acute stroke; or  Had to remain immobile because of a fracture that had not been set or the possibility of a fracture; or  Was experiencing severe hemorrhage; or   Could be moved only by stretcher; or  Was bed -confined before and after the ambulance trip. (b) Cond itions  Review Action  In the absence of any of the conditions listed in (a) above additional documentation should be obtained to establish medical need where the evidence indicates the existence of the circumstances listed below: (i) Patients condition would not ordinarily require movement by stretcher, or  (ii) The individual was  not admitted as a hospital inpatient (except in accident cases), or  (iii) The ambulance was used solely because other means of transportation were unavailable, or  (iv) The individual merely needed assistance in getting from his room or home to a vehicle.  (c)  Where the information indicates a situation not listed in 2(a) or 2(b) above, refer the case to your supervisor. 3. The patient was transported from and to points listed below. (a) From patients residence (or other place where need arose) to hospita l or skilled nursing facility.  3. Claims should show the ZIP Code of the point of pickup. (a) i. Condition met if trip began within the institutions service area as shown in the A/B MAC (B)s locality guide.  ii. Condition met where the trip began outside the institutions service area if the institution was the nearest one with appropriate facilities.  NOTE: A patients residence is the place where he or she makes his/her home and dwells permanently, or for an extended period of time.  A skilled nursing fa cility is one, which is listed in the Directory of Medical Facilities as a participating SNF or as an institution which meets 1861(j)(1)  of the Act.  NOTE:  A claim for ambulance service to a participating  hospital or skilled nursing facility should not be denied on the grounds that there is a nearer nonparticipating institution having appropriate facilities. (b) Skilled nursing facility to a hospital or hospital to a skilled nursing facility.  (b) (i) Condition met if the ZIP Code of the pickup point is within the service area of the destination as shown in the A/B MAC (B)s locality guide.  (ii) Condition met where the ZIP Code of the pickup point is outside the service area of the destination if the destination institution was the nearest appropriate facility.  Cond itions  Review Action  (c) Hospital to hospital or skilled nursing facility to skilled nursing facility.  (c) Condition met if the discharging institution was not an appropriate facility and the admitting institution wa s the nearest appropriate facility.  (d) From a hospital or skilled nursing facility to patients residence.  (d) (i) Condition met if patients residence is within the institutions service area as shown in the A/B MAC (B)s locality guide.  (ii) Condition met where the patients residence is outside the institutions service area if the institution was the nearest appropriate facility.  (e) Round trip for hospital or participating skilled nursing facility inpatients to the nearest hospital or nonhospital tr eatment facility.  (e) Condition met if the reasonable and necessary diagnostic or therapeutic service required by patients condition is not available at the institution where the beneficiary is an inpatient.  NOTE:   Ambulance service to a physicians offi ce or a physician -directed clinic is not covered.  See 10.3. 8 above, where a stop is made at a physicians office en route to a hospital and 10.3.3  for additional exceptions.)  4. Ambulance services involving hospital admissions in Canada or Mexico are covered (Medicare Claims Processing Manual, Chapter 1, General Billing Requirements, 10.1.3.) if the following conditions are met:  4. (a) The foreign hospitalization has been determined to be covered; and  (b) The ambulance service meets the coverage requirements set forth in 10- 10.3.  If the foreign hospitalization has been determined to be covered on the basis of emergency services (See the Medicare Claims Processing Manual, Chapter 1, General Billing Requirements, 10.1.3), the necessity requirement (10.2) and the destination requirement ( 10.3 ) are considered met.  5. The A/B MAC (B) will make partial payment for otherwise covered ambulance service, which exceeded limits defined in item 6.  The A/B MAC (B) will base the payment on the amount payable had the patient been transported:  5 & 6 (a)  From the pickup point to the nearest appropriate facility, or  5 & 6 (b) From the nearest appropriate facility to the beneficiarys residence where he or she is being returned home from a distant institution.   20.1 - Mandatory Assignment Requirements (Rev. 1, 10- 01-03)  When an ambulance prov ider/supplier, or a third party under contract with the provider/supplier, furnishes a Medicare -covered ambulance service to a Medicare beneficiary and the service is not statutorily excluded under the particular circumstances, the provider/supplier must s ubmit a claim to Medicare and accept assignment of the beneficiary's right to payment from Medicare.   20.1.1 - Managed Care Providers/Suppliers  (Rev. 103; Issued:  02- 20-09; Effective Date:  01 -05-09; Implementation Date:  03 -20-09)  Mandatory assignment for ambulance services, in effect with the implementation of the ambulance fee schedule, applies to ambulance providers/suppliers under managed care as well as under fee -for-service.  The ambulance fee schedule is effective for claims with a date of service on or after April 1, 2002.  Any provider or supplier without a contract establishing payment amounts for services provided to a beneficiary enrolled in a Medicare Advantage (MA) coordinated care plan or MA private fee -for-service plan must accept, as pay ment in full, the amounts that they could collect if the beneficiary were enrolled in original Medicare.  The provider or supplier can collect from the MA plan enrollee the cost -sharing amount required under the MA plan, and collect the remainder from the MA organization.  20.1.2 - Beneficiary Signature Requirements  (Rev. 190, Issued: 07- 11-14, Effective: 08- 12-14, Implementation: 08- 12-14)  Medicare requires the signature of the beneficiary, or that of his or her representative, for both the purpose of acc epting assignment and submitting a claim to Medicare.  If the beneficiary is unable to sign because of a mental or physical condition, the following individuals may sign the claim form on behalf of the beneficiary:    (1) The beneficiarys legal guardian.   (2) A relative or other person who receives social security or other governmental benefits on behalf of the beneficiary.   (3) A relative or other person who arranges for the beneficiarys treatment or exercises other responsibility for his or her affairs.   (4) A representative of an agency or institution that did not furnish the services for which payment is claimed, but furnished other care, services, or assistance to the beneficiary.   (5) A representative of the provider or of the nonparticipating hospit al claiming payment for services it has furnished, if the provider or nonparticipating hospital is unable to have the claim signed in accordance with 42 CFR 424.36(b) (1  4).   (6) A representative of the ambulance provider or supplier who is present during an emergency and/or nonemergency transport, provided that the ambulance provider or supplier maintains certain documentation in its records for at least 4 years from the date of service.  A provider/supplier (or his/her employee) cannot request payment for services furnished except under circumstances fully documented to show that the beneficiary is unable to sign and that there is no other person who could sign.  Medicare does not require that the signature to authorize claim submission be obtained at the time of transport for the purpose of accepting assignment of Medicare payment for ambulance benefits.  When a provider/supplier is unable to obtain the signature of the beneficiary, or that of his or her representative, at the time of transport, it may obtain this signature any time prior to submitting the claim to Medicare for payment.  ( Note:  there is a 12 month period for filing a Medicare claim, depending upon the date of service.)  If the beneficiary/representative refuses to authorize the submission of a claim, including a refusal to furnish an authorizing signature, then the ambulance provider/supplier may not bill Medicare, but may bill the beneficiary (or his or her estate) for t he full charge of the ambulance items  and services furnished. If, after seeing this bill, the beneficiary/representative decides to have Medicare pay for these items and services, then a beneficiary/representative signature is required and the ambulance pr ovider/supplier must afford the beneficiary/representative this option within the claims filing period.   30 - Implementation of the Ambulance Fee Schedule  (Rev. 103; Issued:  02- 20-09; Effective Date:  01 -05-09; Implementation Date:  03 -20-09)   The Medicare program ambulance fee schedule (FS) is effective for ambulance items and services furnished on or after April 1, 2002.  Under the FS, payment for ambulance services covered under the program is based on the lower of the actual billed amount or the ambulance fee schedule amount.   The fee schedule was phased in over a 5 -year period.  The fee schedule replaced the retrospective reasonable cost reimbursement system for providers and the reasonable charge system for ambulance suppliers.  During the tran sition period, payment was based on a blend of the FS amount and the amount under its current billing methodology.  The fee schedule applies to all ambulance services, including volunteer, municipal, private, independent, and institutional providers, i.e., hospitals, skilled nursing facilities and home health agencies covered under Medicare Part B, except for services furnished by certain critical access hospitals (CAH).  Payment for ambulance items and services furnished by a CAH, or by an entity that is owned and operated by a CAH, is based on reasonable cost if the CAH or entity is the only provider or supplier of ambulance services that is located within a 35-mile drive of such CAH.  The provision is effective for ambulance services furnished on or after  December 21, 2000.   30.1 - Definition of Ambulance Services  (Rev. 226, Issued: 09- 12-16, Effective: 01- 01-16, Implementation: 12- 12-16)  There are several categories of ground ambulance services and two categories of air ambulance services under the fee s chedule.  (Note that ground refers to both land and water transportation.)  All ground and air ambulance transportation services must meet all requirements regarding medical reasonableness and necessity as outlined in the applicable statute, regulations and manual provisions.  30.1.1 - Ground Ambulance Services  (Rev. 236, Issued: 06- 16-17, Effective: 09- 18-17, Implementation: 09- 18-17)  Basic Life Support (BLS)