Source: http://medpolicy.ibx.com/policies/mpi.nsf/f12d23cb982d59b485257bad00552d87/b8d774839ded7dba85258376004dbb69!OpenDocument
Timestamp: 2019-04-22 08:46:39
Document Index: 104053545

Matched Legal Cases: ['§30', '§20', '§9', '§8', '§8', '§8']

This policy was updated to revise policy coverage criteria regarding Ground Ambulance Services
Policy #: 12.04.02h
Emergency ground ambulance services without transportation of an individual to an emergency facility is considered a benefit contract exclusion for all products of the Company and, therefore, not eligible for reimbursement consideration.
The individual requires oxygen therapy in one of the following circumstances:
Nonemergency ground ambulance transport of a registered inpatient from one acute care facility to another acute care facility to obtain necessary specialized diagnostic and/or therapeutic services is considered medically necessary and, therefore, covered when ALL of the following criteria are met:
A roundtrip nonemergency ground ambulance transport between an eligible point of origin (as defined above) and an eligible destination (as defined above) for an individual to receive eligible medical services not otherwise available at the point of origin is considered medically necessary and therefore covered, when requirements (1) through (5) in this policy are met. Roundtrip nonemergency ground ambulance transport must be reported with the appropriate origin and destination modifier for each segment corresponding to the origin and destination of the roundtrip transport.
Repetitive nonemergency ground ambulance transports, that is three or more round trips (or six one-way trips) within a ten-day period OR at least one trip per week for at least three weeks, is considered medically necessary and, therefore, covered when ALL of the following criteria are met:
A letter of medical necessity stating that transport is medically necessary must be signed by the patient’s attending provider;
The use of extra attendants is eligible for reimbursement consideration when all of the following conditions are met:
Reusable devices and equipment (e.g., backboards, neck boards, inflatable splints) are not eligible for separate reimbursement, regardless of the provider's participation status with the Company, because they are included in the reimbursement for the transport.
Waiting time is not eligible for separate reimbursement because it is always integral to the primary nonemergency ambulance transport code with which it is reported.
Ground ambulance transport services may involve ground or water transport in both emergency and nonemergency situations.
Emergency response means responding immediately at the basic life support (BLS) or advanced life support (ALS) level of services to a 911 call or the equivalent, for the transportation of an individual due to a sudden onset of a medical condition, requiring medical assessment, monitoring, treatment or observation of the individual. An immediate response is one in which the ambulance supplier begins as quickly as possible to take the steps necessary to respond to the call.
American College of Emergency Physicians (ACEP). Policy Statements. Appropriate interfacility patient transfer. [ACEP Web site]. Original: 09/1989. (Revised 01/2016). Available at:https://www.acep.org/patient-care/policy-statements/appropriate-interfacility-patient-transfer/#sm.00006vg9fr1bakdtbz9sgovgpzj01. Accessed September 12, 2018.
Centers for Medicare & Medicaid Services (CMS). Medicare Learning Network (MLN) Matters. SE1514: Overview of the repetitive scheduled non-emergent ambulance prior authorization model. [CMS Web site]. Original:05/04/2015. (Revised 02/14/2018). Available at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE1514.pdf. Accessed August 8, 2018.
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/Medicare-Ambulance-Transports-Booklet-ICN903194.pdf. Accessed August 8, 2018.
Centers for Medicare & Medicaid Services (CMS). Medicare Benefit Policy Manual. Chapter 10 - Ambulance Services. §30.1. Definition of ambulance services. [CMS Web site].(Revision #243: 04/13/18). Available at:https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c10.pdf. Accessed August 8, 2018.
Centers for Medicare & Medicaid Services (CMS). Medicare Benefit Policy Manual. Chapter 10 - Ambulance services. [CMS Web site]. (Revision #243: 04/13/18). Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c10.pdf. Accessed August 8, 2018.
Centers for Medicare & Medicaid Services (CMS). Medicare Managed Care Manual. Chapter 4 - Benefits and beneficiary protections. §20.2. Definitions of emergency and urgently needed services. [CMS Web site]. (Revision #121: 04/22/16). Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/mc86c04.pdf.Accessed August 8, 2018.
Commonwealth of Pennsylvania. PA Code 28, Ch 9, §9.602. Definitions. [The Pennsylvania Code Web site]. Available at: https://www.pacode.com/secure/data/028/chapter9/s9.602.html. Accessed August 8, 2018.
New Jersey (NJ) Administrative Code. Office of Emergency Medical Services. Title 8, Ch 40, Subchapter 1, §8:40-1.3. Mobility assistance vehicle and basic life support ambulance services. [State of NJ Department of Health and Senior Services Web site]. Available at: http://www.state.nj.us/health/ems/documents/reg-enforcement/njac840ar.pdf. Accessed August 8, 2018.
New Jersey (NJ) Administrative Code. Office of Emergency Medical Services. Title 8, Ch 41, Subchapter 1, §8:41-1.3. Advanced life support services; mobile intensive care programs, specialty care transport services and air medical services. [State of NJ Department of Health and Senior Services Web site]. Available at: http://www.state.nj.us/health/ems/documents/reg-enforcement/njac841r.pdf. Accessed August 8, 2018.
New Jersey (NJ) Administrative Code. Office of Emergency Medical Services. Title 8, Ch 41a, Subchapter 1, §8:41a-1.3. Emergency Medical Technicians - Paramedic: training and certification. [NJ Department of Health and Senior Services Web site]. Available at: http://www.state.nj.us/health/ems/documents/reg-enforcement/njac841r.pdf. Accessed August 8, 2018.
Novitas Solutions Inc. LCD L35162 Ambulance Services (Ground Ambulance). Revised effective 07/16/2018. Original effective:10/01/2015. Available at:
https://www.cms.gov/medicare-coverage-database/details/lcd-details.aspx?LCDId=35162&ver=51&Keyword=ambulance&KeywordSearchType=Or&Date=&PolicyType=Both&ArticleType=SAD%7cEd&Cntrctr=323*1&KeyWordLookUp=Doc&SearchType=Advanced&CoverageSelection=Both&kq=true&bc=IAAAACAAAAAA&. Accessed September 10, 2018.
Pennsylvania Department of Health. Bureau of Emergency Medical Services. EMS Information Bulletin 2012-08. 05/03/12. Available at:http://www.health.pa.gov/My%20Health/Emergency%20Medical%20Services/EMS%20in%20PA/Documents/2012/EMSIB%202012-008-Stretcher%20Vans.pdf. Accessed August 8, 2018.
Policy: 12.04.03c: Air Ambulance Services