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

This policy addresses general guidelines applicable to air ambulance services. It should be used as a reference source in conjunction with the member’s benefits, the network provider’s agreement with the Plan, and any applicable ambulance billing guidelines. This policy, the member's benefits, the network provider's agreement with the Plan, and any applicable ambulance billing guidelines are referred to in this policy as "air ambulance criteria."

Air ambulance transportation is covered if the vehicle meets air ambulance criteria, and when the service is medically appropriate.

Air ambulance transportation service is performed by either a rotary wing aircraft (RW) (e.g., helicopter) or fixed wing aircraft (FW), specially designed and equipped for transporting the sick or injured. It must have customary patient care equipment and supplies and also must have safety and lifesaving equipment. The ambulance crew must consist of at least two members. One of these members must have adequate first aid training.

The member’s medical condition must require immediate and rapid ambulance transportation that can not be provided by land ambulance and either:

1. The point of pick-up is inaccessible by land vehicle (this condition could be met in Hawaii, Alaska, and in other remote or sparsely populated areas), or
   
   
2. Great distances or other obstacles (for example, heavy traffic) are involved in getting the patient to the nearest hospital with appropriate facilities for treatment. The term "appropriate facility” refers to a hospital that is capable of providing the required level and type of care for the patient’s illness and has available the type of physician or specialist needed to treat the member’s condition.

Medical Necessity
Medical necessity is established when the member’s condition is such that the time needed to transport a member by land, or the instability of transportation by land, poses a threat to the member’s survival or seriously endangers the member’s health. Following is a list of examples of cases for which air ambulances could be justified. The list is not inclusive of all situations that justify air transportation, nor is it intended to justify air transportation in all locales for the circumstances listed.

• Intracranial bleeding which requires neurosurgical intervention
• Cardiogenic shock (785.51)
• Burns requiring treatment in a Burn Center
• Conditions requiring treatment in a Hyperbaric Oxygen Unit
• Multiple severe injuries
• Life-threatening trauma

Also covered is the transfer of a patient from one hospital to another if medical appropriateness criteria are met and the transferring hospital does not have adequate facilities to provide the medical services needed by the patient. Examples of such services include burn units, cardiac care units, and trauma units. The ambulance transport is covered only if the hospital to which the patient is transferred is the nearest one with appropriate facilities.

Payment will not be made for the use of extra attendants, except when a member's benefits permit extra attendants.

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. A network provider may bill the member for this denied service.

Ground to Air Transport
When a member is transported by ground ambulance and transferred to an air ambulance, the ground ambulance may bill for the level of service provided and mileage from the point-of-pickup to the point-of-transfer to the air ambulance.

In these situations in which a member is transported by ground ambulance to or from an air ambulance, the ground and air ambulance providers must bill independently. Payment will be made to each provider individually for its respective services and mileage.

Additional Mileage
Additional air mileage may be allowed in situations where additional mileage is incurred due to circumstances beyond the pilot’s control. These circumstances include, but are not limited to, the following:

• Military base and other restricted zones, air-defense zones, and similar FAA restrictions and prohibitions;
• Hazardous weather;
• Variances in departure patterns and clearance routes required by an air traffic controller.

If the air transport meets the criteria for medical necessity, claims for air transports may account for all mileage from the point of pickup, including where applicable: ramp to taxiway, taxiway to runway, takeoff run, air miles, roll out upon landing, and taxiing after landing.

Payment When More Than One Ambulance Arrives at the Scene
If no transport of a member occurs, no covered service is rendered. Therefore, when multiple ground and/or air ambulance providers respond, payment may be made only to the ambulance provider that actually furnishes the transport. Ambulance providers that arrive on the scene but do not furnish a transport are not due payment. 

Pronouncement of Death
Payment may be made for an air ambulance service when the air ambulance takes off to pick up a member, but the member is pronounced dead before being loaded onto the ambulance for transport (either before or after the ambulance arrives on the scene). This is provided the air ambulance service would otherwise have been medically necessary. In such a circumstance, the allowed amount is the appropriate air base rate, i.e., fixed wing or rotary wing. However, no amount will be allowed for mileage that would have been allowed had the transport of a living member been completed.

A pronouncement of death is valid only when made by an individual authorized under State law to make such a pronouncement.

Additionally, no payment is made if the dispatcher received pronouncement of death and had sufficient time to notify the pilot to abort the flight. Further, no payment is made if the aircraft has merely taxied but not taken off or, at a controlled airport, has been cleared to take off but has not actually taken off.

Air ambulance companies must use the modifier QL (Patient pronounced dead after ambulance called) to indicate the circumstance when an air ambulance takes off to pick up a member but the member is pronounced dead before the pickup can be made.

Air ambulance companies must maintain documentation, sufficient to show that:

1. The air ambulance was dispatched to pick up a member;
2. The aircraft actually took off to make the pickup;
3. The member to whom the dispatch relates was pronounced dead before being loaded onto the ambulance for transport;
4. The pronouncement of death was made by an individual authorized by State law to make such a pronouncement; and
5. The dispatcher did not receive notice of such death pronouncement in sufficient time to permit the flight to be aborted before take off.

Miscellaneous

• Air ambulance services are not covered for transport to a facility that is not an acute care hospital, such as a nursing facility, physician’s office or a member’s home.
  
  
• More than one patient may be transported in the ambulance.  The billed amount should be prorated by the number of patients in the ambulance.
  
  
• If a determination is made that the transport by an ambulance was necessary, but land ambulance service would have sufficed, payment for the air ambulance service should be based on the amount payable for land transport, if less costly.
  
  
• If the air transport was medically appropriate but the member could have been treated at a nearer hospital than the one to which they were transported, the air transport payment is limited to the rate to the nearer hospital.

This medical policy is not an authorization, certification, or contract with respect to member benefits and is not an explanation of benefits. 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.

Local professional ambulance transport services to or from the nearest hospital equipped to adequately treat the member's condition are covered when medically appropriate, and:

• associated with covered hospital inpatient care;
• related to medical emergency or accidental injury; or
• associated with covered hospice care.

NOTE:

We also cover medically necessary emergency care provided at the scene when transport services are not required.

Highmark Medicare Services Ambulance Billing Guide