Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › COVERED SERVICES › SUB AREA: MEDICAL TRANSPORTATION SERVICES › Section 16.03.09.865 - EMERGENCY TRANSPORTATION SERVICES: PROVIDER REIMBURSEMENT

Current through August 31, 2023
01.
Scope of Coverage and General
				  Requirements for Ambulance Services
. Ambulance service review is
				  governed by provisions of the Transportation Policies and Procedures Manual as
				  amended. If such review identifies that an ambulance service is not covered,
				  then no Medicaid payment will be made for the ambulance service. Reimbursement
				  for ambulance services originally denied by the Department will be made if such
				  decision is reversed by the appeals process required in IDAPA 16.05.03,
				  "Contested Case Proceedings and Declaratory Rulings." Payment for ambulance
				  services is subject to the following limitations: (3-17-22)
02.
Ambulance Reimbursement
.
				  (3-17-22)
a. The base rate for ambulance
				  services includes customary patient care equipment and items such as
				  stretchers, clean linens, reusable devices and equipment. The base rate also
				  includes nonreusable items, and disposable supplies such as oxygen, triangular
				  bandages and dressings that may be required for the care of the participant
				  during transport. In addition to the base rate, the Department will reimburse
				  mileage. (3-17-22)
b. Charges for
				  extra attendants are not covered except for justified situations and must be
				  authorized by the Department. (3-17-22)
c. If a physician is in attendance during
				  transport, they are responsible for the billing of their services.
				  (3-17-22)
d. Reimbursement for
				  waiting time will not be considered unless documentation submitted to the
				  Department identifies the length of the waiting time and establishes its
				  medical necessity or indicates that it was physician ordered. Limited waiting
				  time will be allowed for round trips. (3-17-22)
e. Ambulance units are licensed by the EMS
				  Bureau of the Department, or other states' EMS licensing authority according to
				  the level of training and expertise its personnel maintain. At least this level
				  of personnel is required to be in the patient compartment of the vehicle for
				  every ambulance trip. The Department will reimburse a base rate according to
				  the following: (3-17-22)
i. The level of
				  personnel required to be in the patient compartment of the ambulance;
				  (3-17-22)
ii. The level of
				  ambulance license the unit has been issued; and (3-17-22)
iii. The level of life support authorized by
				  the Department. (3-17-22)
f. Units with Emergency Medical Technician -
				  Basic (EMT-B) or equivalent personnel in the patient compartment of the vehicle
				  will be reimbursed up to the Basic Life Support (BLS) rate. Units with Advanced
				  Emergency Medical Technician-Ambulance (AEMT-A) or equivalent personnel in the
				  patient compartment of the vehicle will be reimbursed up to the Advanced Life
				  Support, Level I (ALSI) rate. Units with Emergency Medical Technician -
				  Paramedic (EMT-P) or equivalent personnel in the patient compartment of the
				  vehicle will be reimbursed up to the Advanced Life Support, Level II (ALSII)
				  rate. When a participant's condition requires hospital-to-hospital transport
				  with ongoing care that must be furnished by one (1) or more health care
				  professionals in an appropriate specialty area, including emergency or critical
				  care nursing, emergency medicine, or a paramedic with additional training,
				  Specialty Care Transport (SCT) may be authorized by the Department.
				  (3-17-22)
g. If multiple licensed
				  EMS providers are involved in the transport of a participant, only the
				  ambulance provider who actually transports the participant will be reimbursed
				  for the services. (3-17-22)
i. In situations
				  where personnel and equipment from a licensed ALSII provider boards an ALSI or
				  BLS ambulance, the transporting ambulance may bill for ALSII services as
				  authorized by the Department. (3-17-22)
ii. In situations where personnel and
				  equipment from a licensed ALSI provider boards an ALSII or BLS ambulance, the
				  transporting ambulance may bill for ALSI services as authorized by the
				  Department. (3-17-22)
iii. In
				  situations where medical personnel and equipment from a medical facility are
				  present during the transport of the participant, the transporting ambulance may
				  bill at the ALSI or ALSII level of service. The transporting provider must
				  arrange to pay the other provider for their services. The only exception to the
				  preceding policy is in situations where medical personnel employed by a
				  licensed air ambulance provider boards an ALSI, ALSII, or BLS ground ambulance
				  at some point, and the air ambulance medical personnel also accompany and treat
				  the participant during the air ambulance trip. In this situation, the air
				  ambulance provider may bill the appropriate base rate for the air ambulance
				  trip, and may also bill the charges associated with their medical personnel and
				  equipment as authorized by the Department. (3-17-22)
iv. The ground ambulance provider may also
				  bill for their part of the trip as authorized by the Department.
				  (3-17-22)
h. If multiple
				  licensed EMS providers transport a participant for different legs of a trip,
				  each provider must bill their base rate and mileage, as authorized by the
				  Department. (3-17-22)
i. If a
				  licensed transporting EMS provider responds to an emergency situation and
				  treats the participant, but does not transport the participant, the Department
				  may reimburse for the treat and release service. The Department will reimburse
				  the appropriate base rate. This service requires authorization from the
				  Department, usually on a retrospective basis. (3-17-22)
j. If an ambulance vehicle and crew have
				  returned to a base station after having transported a participant to a facility
				  and the participant's physician orders the participant to be transferred from
				  this facility to another facility because of medical need, two (2) base rate
				  charges, in addition to the mileage, will be considered for reimbursement. If
				  an ambulance vehicle and crew do not return to a base station and the patient
				  is transferred from one (1) facility to another facility, charges for only one
				  (1) base rate, waiting time, and mileage will be considered.
				  (3-17-22)
k. Round trip charges
				  will be allowed only in circumstances when a facility in-patient is transported
				  to another facility to obtain specialized services not available in the
				  facility in which the participant is an in-patient. The transport must be to
				  and from a facility that is the nearest one with the specialized services.
				  (3-17-22)
l. If a licensed
				  transporting EMS provider responds to a participant's location and upon
				  examination and evaluation of the participant, finds that their condition is
				  such that no treatment or transport is necessary, the Department will pay for
				  the response and evaluation service. This service requires authorization by the
				  Department, usually on a retrospective basis. No payment will be made if the
				  EMS provider responds and no evaluation is done, or the participant has left
				  the scene. No payment will be made to an EMS provider who is licensed as a
				  non-transporting provider. (3-17-22)