Ambulance transportation is a benefit under many, but not all, of Mountain State's products. When a benefit, coverage is made in accordance with all appropriate contractual provisions and limitations.

This policy addresses general guidelines applicable to ambulance services. It should be used as a reference source in conjunction with the member’s benefits, the network provider’s agreement with Mountain State, and any applicable ambulance billing guidelines.

Medical Necessity
To be covered, ambulance transportation must be medically necessary. Medical necessity is established when the patient's clinical condition is such that the use of any other method of transportation, such as taxi, private car, or other type of vehicle would be contraindicated (i.e., would endanger the patient's medical condition).

The patient's condition at the time of the transport is the determining factor in whether a trip will be covered. The fact that the patient is elderly, has a positive medical history, or cannot care for himself/herself does not establish medical necessity.

Payment will not be made for ambulance service when an ambulance was used simply for convenience or because other means of transportation was not available.

Reimbursement may be made for expenses incurred by a patient for ambulance services that meet the following conditions:

1. Was transported in an emergency situation, e.g., as a result of an accident, injury or acute illness, or 
2. Needed to be restrained, or
3. Was unconscious or in shock, or
4. Required oxygen or other emergency treatment on the way to his destination, or
5. Had to remain immobile because of a fracture that had not been set or the possibility of a fracture, or
6. Sustained an acute stroke or myocardial infarction, or
7. Was experiencing severe hemorrhage, or
8. Was bed confined before and after the ambulance trip (see note below), or
9. Could be moved only by stretcher

NOTE: "Bed confinement" is defined as (all three conditions must be met):

The patient is:

• unable to get up from bed without assistance;
• unable to ambulate; and
• unable to sit in a chair or wheelchair.

Vehicle and Crew Requirements
Any vehicle used as an ambulance must be designed and equipped to respond to medical emergencies, and, in non-emergency situations, be capable of transporting members with acute medical conditions. The vehicle must comply with state or local laws governing the licensing and certification of an emergency medical transportation vehicle. At a minimum, the ambulance must contain a stretcher, linens, emergency medical supplies, oxygen equipment, and other lifesaving emergency medical equipment and be equipped with emergency warning lights, sirens, and telecommunications equipment as required by state or local law. This should include, at a minimum, one two-way voice radio or wireless telephone.

No Transport
If no transport of a member occurs (A0998), no covered service is rendered. Therefore, payment will not be made to the ambulance company. This applies to situations in which the member refuses to be transported, even if medical services are provided prior to loading the member onto the ambulance (e.g., BLS or ALS assessment). A network provider can bill the member for this denied service.

Destination Requirements
For an ambulance trip to be covered, the patient must be transported to the closest local facility that has appropriate facilities for treatment. The term "appropriate facilities" means that the institution is generally equipped to provide the needed hospital or skilled nursing care for the illness or injury involved. In the case of a hospital, it also means that a physician is available to provide the necessary care required to treat the patient's condition.

Pronouncement of Death
No payment will be made if the member was pronounced dead prior to the time the ambulance was called. The following scenarios apply to payment for ambulance services when the member dies:

• The member is pronounced dead after the ambulance is called but before the ambulance arrives at the scene:
  
  Payment may be made for a BLS base rate; no mileage adjustment will be made. Use the QL modifier (patient pronounced dead after the ambulance was called).
  
  
• The member is pronounced dead after being loaded into the ambulance (regardless of whether the pronouncement is made during or subsequent to the transport):
  
  Payment is made following the usual rules of payment as if the member had not died. This scenario includes a determination of "dead on arrival" (DOA) at the facility to which the member was transported.

NOTE:

Notwithstanding the member's apparent condition, the death of a member should be recognized only when the pronouncement of death is made by an individual who is licensed or otherwise authorized under state law to pronounce death in the state where such pronouncement is made.

BLS/ALS Joint Responses
In situations where a BLS (Basic Life Support) supplier provides the transport of the member and an ALS (Advanced Life Support) supplier provides a service that meets the definition of ALS intervention (e.g., ALS assessment, Paramedic Intercept services), the BLS supplier may bill the higher ALS rate, only if there is a written agreement between the BLS and ALS suppliers. Suppliers must provide a copy of the agreement or other such evidence (e.g., signed attestation) upon request.

Paramedic intercept services (S0207, S0208) are ALS services provided by paramedics who are not part of the ambulance entity that is providing the actual patient transportation. If paramedic intercept services are provided by an ALS supplier who does not have an agreement with the BLS supplier and if those services are reported independent of ambulance transportation, they are not covered.  A network provider can bill the member for this denied service.

Supplies
Certain supplies that are non-reusable and disposable may be covered. Codes A0382, A0392, A0394, A0396, and A0398 should be used to report these items. Invoices showing the cost of disposable supplies must be kept on file and available upon request.

Supplies that are considered personal care items or are packaged in quantities are considered part of the base rate, not separately reimbursable.  These include, but are not limited to:

• Alcohol wipes
• Band aids
• Blood glucose reagent strips
• Emesis basin
• Lancets
• Tape
• Urinal
• Urine reagent strips

Supply codes A0382, A0392, A0396, and A0398 will only be reimbursed once per transport, regardless of the number of items used during the transport. Supply code A0394 may be reimbursed twice per transport, but only if two IV’s were started.

No payment may be made for reusable devices and equipment such as backboards, neckboards, inflatable splints, or linens (disposable or not). Such items and services are considered a part of the charge for the ambulance trip. Payment for the ambulance trip includes payment for these items and services.

Separate payment will not be made for protective garments worn by ambulance personnel. Protective garments include items such as disposable gloves (A4927, A4930), goggles, masks (A4928), gowns, or any other disposable supply worn by the ambulance staff. This type of supply is considered included in the base rate; therefore they are not separately payable items. A network provider cannot bill the member for the denied service.

Miscellaneous

• Individual procedure codes for service and mileage, along with the number of miles, must be reflected on the claim.
  
  
• Ambulance suppliers are required to retain documentation on file supporting all ambulance services (i.e., trip sheets).
  
  
• When multiple units respond to a call for services, payment will be made to the entity that provides the transport for the member. The transporting entity should bill for all services furnished.
  
  
• More than one patient may be transported, e.g., from the scene of a traffic accident. The billed amount should be prorated by the number of patients in the ambulance.
  
  
• When multiple patient transports are reported, the statement "multiple patients" and the number transported must be documented.
  
  
• Based upon the state licensure requirements for an ambulance vehicle and crew members, cardiac monitoring is considered an ALS specialized service. Therefore, it is not recognized as a service performed in conjunction with a BLS transport.
  
  
• The fee for cardiac monitoring, including EKG’s (93000-93010, 93040-93042), is included in the base rate for codes A0426, A0427, A0433, and A0434. The billed amount should reflect the base rate, including cardiac monitoring services.
  
  
• Payment will not be made for ambulance services that are provided for patient or family convenience.
  
  
• Payment will not be made for waiting time (A0420) and the use of extra attendants (A0424), except for certain groups/programs identified in benefits.
  
  
• Pulse oximetry (94760, 94761) is not separately reimbursable as it is considered an inherent part of ambulance transport. Therefore, it is not covered. A network provider cannot bill the member for the denied service.
  
  
• Payment will not be made for ambulance night differential charges for ambulance transport provided between the hours of 7PM and 7AM (A0800), as it is considered an inherent part of the base rate for ambulance transport.  Code A0800 will be denied as not covered. A network provider cannot bill the member for the denied service.

Refer to Medical Policy Bulletin Q-5 for guidelines specific to air ambulance services.

Coverage for Ambulance Services is determined according to individual or group customer benefits.

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

FEP pays for medically necessary paramedic intercept or paramedic services under code A0424.

PRN References

10/2001, Cardiac monitoring code Z0224 to be deleted
10/2003, New coverage guidelines for select ambulance services outlined
10/2003, FEP pays for paramedic intercept