1 Initial Proposal DRAFT 6/21/12 1 Readopt with amendment He-W 572, effective 5/30/06 (Document #8638), as amended effective 7/1/12 (Document #10139), to read as follows:] PART He-W 572 AMBULANCE SERVICES He-W Definitions. (a) Acute care hospital means a hospital that provides short-term medical treatment for patients who have an acute illness or injury, or who are recovering from surgery. (b) Advanced life support (ALS) services means services provided by an ambulance certified to provide specialized life-sustaining services and equipment such as intravenous medication, anti-shock trousers, establishing and maintaining a patient s airway, defibrillating the heart, relieving pneumothorax conditions, and EKG monitoring within the scope of practice rendered by advanced emergency medical care providers in accordance with RSA 153-A:2. (c) Air ambulance means a fixed-wing or rotary-wing aircraft that is certified by the Federal Aviation Administration as an air ambulance and which is designed and equipped for the provision of medically necessary supplies and services. (c)(d) Ambulance means any vehicle designed, equipped, and used for the transport of sick or injured individuals and which are licensed to do so in the state in which they operate. (d) Ambulance services means advanced life support services or basic life support services. (e)(e) Basic life support (BLS) services means services provided by an ambulance that provides transportation plus the equipment and staff needed for such services as control of bleeding, splinting fractures, treatment for shock, delivery of babies, and cardio-pulmonary resuscitation within the scope of non-invasive practice rendered by emergency medical care providers. (f) Department means the New Hampshire department of health and human services. (g) Emergency medical condition means, based on 42 USC 1395dd(e)(1): (1) A medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected to result in: a. Placing the health of the recipient, or, with respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy; b. Serious impairment to bodily functions; or c. Serious dysfunction of any bodily organ or part; or (2) With respect to a pregnant woman who is having contractions: a. That there is inadequate time to effect a safe transfer to another hospital before delivery; or b. That transfer may pose a threat to the health or safety of the woman or unborn child.
2 Initial Proposal DRAFT 6/21/12 2 (f)(h) Medicaid means the Title XIX and Title XXI programs administered by the department which makes medical assistance available to eligible individuals. (g) Medically necessary meansreasonably calculated to prevent, diagnose, correct, cure, alleviate, or prevent the worsening of conditions that endanger life, cause pain, result in illness or infirmity, threaten to cause or aggravate a handicap, or cause physical deformity or malfunction, and no other equally effective course of treatment is available or suitable for the recipient requesting a medically necessary service. (i) Prior authorization agent means an individual or agency contracted by the department responsible for reviewing all non-emergency ambulance transportation requests. (h)(j) Recipient means an individual who is eligible for and receiving medical assistance under the medicaid program. (i)(k) Title XIX means the joint federal-state program described in Title XIX of the Social Security Act and administered in New Hampshire by the department under the medicaid program. (j)(l) Title XXI means the joint federal-state program described in Title XXI of the Social Security Act and administered in New Hampshire by the department under the medicaid program. He-W Recipient Eligibility. All Title XIX recipients shall be eligible for ambulance services, in accordance with He-W 572. He-W Provider Participation. All participating ambulance providers shall: (a) Be licensed in the state in which they practiceoperate; and (b) Be an enrolled New Hampshire Title XIX provider. He-W Covered Services. (a) The following ambulance services, in the case of an emergency medical condition, shall be covered: Formatted: Font: Bold Formatted: Indent: First line: 0" (a)(1) Transportation, in the case of a medical emergency, to and from the nearest acute care hospital with appropriate treatment facilities, including loaded mileage and routine disposable supplies used en-route; (b) Transportation to medical providers when other methods of transportation are medically contraindicated due to the recipient s condition, and when documented in accordance with He-W ; (c)(2) Transportation from one acute care hospital to another acute care hospital when the necessary treatment cannot be provided by the initiating acute care hospital and the recipient is admitted to the second hospital; and (3) Waiting time for transportation as follows: a. Prior to transporting the recipient while the recipient is being stabilized; and b. Up to a maximum of 2 hours, rounded to the nearest half-hour.
3 Initial Proposal DRAFT 6/21/12 3 (b) Air ambulance services, in the case of an emergency medical condition, shall be covered if the recipient s condition is such that: (1) The recipient cannot be safely transported in a timely basis via an ALS ground transportation with appropriate staff; and (2) The recipient is at imminent risk of losing life or limb if the fastest means of transport is not utilized to move the recipient to the nearest facility capable of treating the recipient. (c) Non-emergency ambulance transportation for medical treatment to and from the destination, including loaded mileage and routine disposable supplies used en-route, shall be covered when the service is authorized in accordance with He-W ; (d) Waiting time, for non-emergency ambulance transportation authorized pursuant to He-W shall be covered up to a maximum of 2 hours, rounded to the nearest half hour, except for waiting time in accordance with He-W (f). He-W Non-Covered Services. Non-covered ambulance services shall include: (a) Transportation for a recipient whose condition permits transport in any type of vehicle other than an ambulance, such as a private vehicle or a wheelchair van, without endangering the recipient s health, whether or not such other vehicle is actually available. Formatted: Left, Indent: Left: 0.75", Space After: 0 pt, Adjust space between Latin and Asian text, Adjust space between Asian text and numbers, Tab stops: 0.42", Left ", Left ", Left ", Left ", Left ", Left ", Left Formatted: Font: Not Bold, Font color: Auto Formatted: Indent: Left: 0.75", First line: 0" (a)(b) Transportation by ambulance only for the patient s recipient s or his or her family s convenience; (b)(c) Transportation to and from medical providers, except as provided in He-W (b)unless authorized in accordance with He-W ; (c)(d) Transportation from one acute care hospital to another acute care hospital, except as allowed by He-W (a)(2) unless the initiating acute care hospital is unable to provide the necessary treatment to the recipient; (d) Transportation from a nursing facility to a physician s office if the physician service could be provided in the nursing facility; (e) Waiting time, as follows: (1) Waiting time that exceeds 2 hours; and (2) Waiting time for transportation in the case of an emergency medical condition when the wait is not due to the recipient needing to be stabilized. (f) Waiting time, if it is incurred due to a shortage of staff within the treating acute care hospital. He-W Authorization Requirements for Non-Emergency Ambulance Transportation. (a) Non-emergency ambulance transportation shall require authorization to be a covered service. (b) A complete authorization request shall:
4 Initial Proposal DRAFT 6/21/12 4 (1) Be submitted by the ambulance provider to the department or its prior authorization agent by either fax or mail; and (2) Include the following forms, completed and legible: a. Form XXX Non-Emergency Ambulance Transportation Authorization Request Form (EDITION DATE) signed and dated by the ambulance provider; and b. Form XXX Medical Certification for Scheduled Non-Emergency Ambulance Transportation (EDITION DATE) dated and signed by the recipient s attending physician, doctor of osteopathy, physician assistant, clinical nurse specialist, advanced practice registered nurse, registered nurse, or discharge planner employed by the facility where the recipient is being treated. (c) Authorization requests shall be submitted prior to or within 30 days of the service being delivered. (d) A complete authorization request shall be approved by the department or its prior authorization agent if: (1) The recipient is bed confined, as described in (e) below; or (2) The recipient has a condition such that all other methods of transportation are contraindicated by the recipient s condition and therefore, the recipient cannot be transported by any other means from the origin to the destination without endangering the recipient s health. (e) In order to be considered bed confined, a recipient shall be: (1) Unable to get up from bed without assistance; (2) Unable to ambulate; and (3) Unable to sit in a chair or wheelchair. (f) Authorizations shall be approved for a specified number of trips over a specified period of time, not to exceed a maximum of 3 months, after which a new complete authorization request shall be submitted in accordance with (b) above. (g) If the department or its prior authorization agent denies the authorization request, it shall forward a notice of denial to the recipient and the requesting provider on the department Form 272a, Medical Assistance Program Denial for Prior Authorized Services, including the following: (1) The reason for, and legal basis of, the denial; and (2) Information that a fair hearing on the denial may be requested within 30 calendar days of the date on the notice of the denial, in accordance with He-C 200. He-W Documentation.
5 Initial Proposal DRAFT 6/21/12 5 (a) Each ambulance provider shall maintain supporting records in accordance with He-W 520. (b) Each ambulance provider shall maintain documentation in their records to fully support each claim billed for services, including: (1) For emergency transportation, documentation of the nature of the recipient s emergency medical condition; and (2) For all ambulance transportation, documentation that justifies the level of service, whether ALS or BLS, claimed. (c) For each trip billed in (b) above, the ambulance provider shall maintain a run sheet or patient care report that includes at a minimum the following information, which is legibly written: (1) Recipient name and medicaid identification number; (2) Date of service; (3) Origin and destination; (4) Recipient vital signs; (5) Recipient signs and symptoms upon arrival at the point of pick-up; (6) Recipient status en-route; (7) Services provided; (8) The name of the person who provided the service or care in the ambulance, including signature and credentials; and (9) The response code that indicates the mode of response for the ambulance making the trip. He-W Documentation. Ambulance services shall be documented as medically necessary by using the ALS or BLS ambulance medical necessity form as follows: (a) The ALS or BLS ambulance medical necessity form: (1) May be downloaded from and (2) Shall be completed by someone with medical knowledge of the case, and signed by a physician, physician assistant, advanced registered nurse practitioner, registered nurse, clinical nurse specialist, or discharge planner; (b) When ALS services are provided, ambulance services providers shall retain and provide to the department or the medicaid fraud control unit of the New Hampshire department of justice (NHDOJ) when requested, the ALS ambulance medical necessity form, containing the following: (1) Recipient s name; (2) Recipient s NH medicaid identification number;
6 Initial Proposal DRAFT 6/21/12 6 (3) Recipient s date of birth; (4) Place to where ambulance was dispatched; (5) Date dispatched; (6) Place to where the recipient was taken; (7) The suspected diagnosis or presenting symptoms; (8) The emergency care provided; (9) Other pertinent information, if applicable; (10) Ambulance provider number; (11) Name of the person who completed the form; and (12) Dated signature of a physician, physician assistant, advanced registered nurse practitioner, registered nurse, clinical nurse specialist, or discharge planner. (c) When BLS services are provided, ambulance services providers shall retain and provide to the department or the NHDOJ when requested, the BLS ambulance medical necessity form, containing the following: (1) Recipient s name; (2) Recipient s NH medicaid identification number; (3) Recipient s date of birth; (4) Place to where ambulance was dispatched; (5) Date dispatched; (6) Place to where the recipient was taken; (7) Description of the recipient s condition; (8) Whether or not the recipient was ambulatory; (9) Whether the recipient was able to utilize other modes of transportation without endangering the recipient s condition; (10) Services performed if the recipient was transported to the outpatient department of a hospital; (11) Reason for transferring the recipient from one institution to another, if applicable; (11) Name of the person who completed the form;
7 Initial Proposal DRAFT 6/21/12 7 (13) Ambulance provider number; and (14) Dated signature of a physician, physician assistant, advanced registered nurse practitioner, registered nurse, clinical nurse specialist, or discharge planner. (d) If electronic billing is used, the provider shall retain an ambulance medical necessity form at the provider location to support each claim; (e) If paper billing is used, the provider shall retain an original ambulance medical necessity form at the provider location and attach a copy to the paper claim form; and (f) The ambulance services provider shall maintain supporting records, in accordance with He-W He-W Utilization Review and Control. The department shall monitor utilization of ambulance services, in accordance with 42 CFR 455, 42 CFR 456, and He-W 520. He-W Third Party Liability. All third party obligations shall be exhausted before Title XIX may be billed, in accordance with 42 CFR He-W Payment for Services. (a) Payment for ambulance services shall be made in accordance with the rates established by the department. in accordance with RSA 161:4, VI(a). (b) Payment shall consist of the following separate components, as applicable: (1) A base rate; (2) A mileage rate, which shall be paid for the most direct route to and from a destination and for loaded miles only, which: a. Shall be the distance traveled while transporting a recipient from a pick-up point to a drop-off point; and b. Does not include mileage incurred on the way to pick up a recipient or after dropping off a recipient; (3) Payment for waiting time, as allowed by He-W (a)(3) and (d); and (4) Payment for routine disposable supplies used en-route. (b) Payment shall be made for loaded miles only, which means the distance traveled while transporting recipients from a pick-up point to a drop-off point, not including mileage incurred on the way to pick up a recipient or after dropping off a recipient. (c) Payment shall be made for only one mileage charge per trip regardless of the number of recipients transported.
8 Initial Proposal DRAFT 6/21/12 8 (d) Payment shall be based on the level of service provided, not on the vehicle used, even if the local government requires an ALS response for all calls. (e) The ambulance provider shall not bill Title XIX for transporting a recipient from an acute care hospital to another acute care hospital or medical provider, to obtain diagnostic testing not available while the recipient is still an inpatient of the acute care hospital. (f) The ambulance provider shall submit claims for payment to the department s fiscal agent. in the following manner: (1) If paper claims are submitted, a copy of the ambulance medical necessity form shall be attached to each claim; and (2) If electronic billing is used, the provider shall retain an ambulance medical necessity form at the provider location to support each claim. APPENDIX RULE STATE OR FEDERAL STATUTE THE RULE IMPLEMENTS He-W CFR He-W CFR , 42 CFR He-W CFR , RSA 153A-11, 42 CFR He-W CFR He-W CFR He-W CFR He-W CFR He-W CFR 455 He-W CFR He-W RSA 541-A:21, III, 42 CFR , 42 CFR , 42 CFR
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