Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter III - Allowances for Services › Section 144-101-III-5 - AMBULANCE SERVICES › Subsection 144-101-III-5.06 - FEE SCHEDULE

Current through 2024-29, July 17, 2024
PROC. CODE
DESCRIPTION
MAXIMUM ALLOWANCE EFFECTIVE
								  3/1/15-12/31/19
MAXIMUM ALLOWANCE EFFECTIVE
								  1/1/2020
PRIOR AUTH.
REQUIRES MODIFIER
A0021
AMBULANCE SERVICE; OUT OF STATE; PER MILE
								  TRANSPORT [Out-of-state ambulance providers bill this code.]
$2.00
$2.00
YES
A0225
AMBULANCE SERVICE; SPECIALIZED NEONATAL
								  TRANSPORT, BASE RATE EMERGENCY ONE WAY [GROUND][Birth to 2 years of age] (SEE
								  NOTE E)
$300.00
100% of current published Medicare rate
								  ***
A0420
AMBULANCE WAITING TIME (ALS OR BLS), ONE HALF
								  (1/2) HOUR INCREMENTS
[starting with the second completed half hour at one
								  half hour per unit]
$95.00
$95.00
A0424
EXTRA AMBULANCE ATTENDANT, ALS OR BLS (REQUIRES
								  MEDICAL REVIEW)
$32.00
$32.00
YES
A0425
GROUND MILEAGE, PER STATUTE MILE
65% of current published Medicare rate*
100% of current published Medicare rate***
A0425
GROUND MILEAGE, PER STATUTE MILE-INVOLUNTARY
								  ADMISSION TO A PSYCHIATRIC FACILITY
$8.00
$8.00
YES
SEE NOTE D
A0426
AMBULANCE SERVICE, ADVANCED LIFE SUPPORT,
								  NON-EMERGENCY TRANSPORT, LEVEL 1 [ALS 1]
65% of current published Medicare rate*
100% of current published Medicare rate***
A0427
AMBULANCE SERVICE, ADVANCED LIFE SUPPORT,
								  EMERGENCY TRANSPORT, LEVEL 1 [ALS 1-EMERGENCY]
65% of current published Medicare rate*
100% of current published Medicare rate***
A0428
AMBULANCE SERVICE, BASIC LIFE SUPPORT,
								  NON-EMERGENCY TRANSPORT, [BLS]
65% of current published Medicare rate*
100% of current published Medicare rate***
A0428
AMBULANCE SERVICE, BASIC LIFE SUPPORT,
								  NON-EMERGENCY TRANSPORT, [BLS]-INVOLUNTARY ADMISSION TO A PSYCHIATRIC
								  FACILITY
$285.00
$285.00
YES
SEE NOTE D
A0429
AMBULANCE SERVICE, BASIC LIFE SUPPORT, EMERGENCY
								  TRANSPORT [BLS-EMERGENCY]
65% of current published Medicare rate*
100% of current published Medicare rate***
A0430
AMBULANCE SERVICE, CONVENTIONAL AIR SERVICES,
								  TRANSPORT, ONE-WAY [FIXED WING] (SEE NOTE B)
65% of current published Medicare rate*
100% of current published
Medicare rate***
**
A0431
AMBULANCE SERVICE, CONVENTIONAL AIR SERVICES,
								  TRANSPORT, ONE-WAY [ROTARY WING] (SEE NOTE C)
65% of current published Medicare rate*
100% of current published Medicare rate***
**
A0433
ADVANCED LIFE SUPPORT, LEVEL 2 [ALS 2]
65% of current published Medicare rate*
100% of current published Medicare rate***
A0434
SPECIALTY CARE TRANSPORT [SCT]
65% of current published Medicare rate*
100% of current published Medicare rate***
A0435
FIXED WING AIR MILEAGE, PER STATUTE MILE
65% of current published Medicare rate*
100% of current published Medicare rate***
**
A0436
ROTARY WING AIR MILEAGE, PER STATUTE MILE
65% of current published Medicare rate*
100% of current published Medicare rate***
**
A0998
AMBULANCE RESPONSE AND TREATMENT, NO
								  TRANSPORT
$95.00
$95.00
A0999
UNLISTED AMBULANCE SERVICE (SEE NOTE A)
See Note A
YES
*Maximum allowance set at 65% of the current
						published Medicare rate is effective March 1, 2015, and upon approval by
						CMS.
**All out of state services require prior
						authorization.
***Maximum allowance set at 100% of the current
						published Medicare rate is effective retroactive to January 1, 2020. The
						Department shall submit to CMS and anticipates approval for a State Plan
						Amendment related to these provisions.