SUBSCRIPTION TERMS AND CONDITIONS

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1 SUBSCRIPTION TERMS AND CONDITIONS Subscribers of Jefferson Hills Area Ambulance Association hereinafter referred to as JHAAA, receive the benefit of unlimited access to basic and advanced life support emergency ambulance service, throughout the coverage area, when JHAAA is available to respond throughout the term of the subscription year. Subscription enrollment may occur anytime during the calendar year with each subscription to be paid in the full amount. All subscriptions expire on June 30 th of each respective calendar year regardless of the date when the subscription is paid. The subscription program is neither an insurance contract nor a solicitation of insurance premiums. This is also not a solicitation to persons receiving medical assistance benefits. Jefferson Hills Area Ambulance Association is recognized and licensed by the Pennsylvania Department of Health as both an Advanced Life Support (ALS) and Basic Life Support (BLS) Ambulance Service Provider. JHAAA will provide care and practice through the Medical Direction of Jefferson Regional Medical Center and/or a recognized Medical Command Facility per Pennsylvania Department of Health guidelines. A valid subscription provides protection against any unnecessary fees related to certain medical transportation services provided by JHAAA as outlined in this document. Subscription fees are applied to all available co-payments and deductibles which can save subscribers hundreds of dollars each year. Subscribers are not responsible for any out-of-pocket expenses or fees except as required by law or regulation or otherwise outlined in this document. Subscribers are entitled to unlimited emergency medical services, as described herein, within the coverage area; Jefferson Hills Area Ambulance Association JHAAA is the recognized Emergency Ambulance provider for the following municipalities which currently includes: Jefferson Hills Borough, Union Township, Forward Township West Elizabeth Borough All set provisions pursuant to our annual subscription drive are enacted for our designated communities listed above. Page 1 of 12

2 ALL RESIDENTS REQUIRING EMERGENCY MEDICAL SERVICES within JHAAA MUNICIPALITIES SHOULD MAKE REQUESTS BY DIALING 911. Subscription coverage becomes effective upon receipt and acceptance of the subscription application by JHAAA. Emergency responses always have priority over other types of non-emergency transportation services. Emergency ambulance services are subject to emergency vehicle availability, staffing, scheduling, equipment and other system constraints. JHAAA, in consultation with its medical Command Physicians, reserve the exclusive right to make all decisions regarding medical transportation services and the destination provided to all patients, including subscribers. These decisions will be made based primarily upon the patient s medical condition at the time of service and applicable laws of the Commonwealth of Pennsylvania and other regulations as promulgated by the Pennsylvania Department of Health s Advanced Life Support (ALS) and or Basic Life Support (BLS) Statewide Protocols. Secondary considerations include, but are not limited to, patient or family requests, the capability and availability of relevant medical services at a receiving medical facility, current policies and procedures and the availability of the EMS system and hospital resources. JHAAA will attempt to transport the patient to the hospital of their choice. In certain circumstances, JHAAA reserves the right to make the determination of the destination. Such circumstances include, but are not limited to: Patient condition [if transport to a further hospital could be detrimental to the patient s condition] Specialized care [ if the patient requires specialized Trauma, Obstetrics, Pediatric, Stroke or Cardiac care] Extreme weather conditions [in extreme weather conditions, JHAAA will transport patients to the closest appropriate facility for patient and crew safety] Aeromedical Transport: JHAAA reserves the right to use Aeromedical evacuation of patients which meet the Statewide Protocol Criteria and to where time is deemed as of the essence and transportation by ground would delay transportation times and could be detrimental to the patient. Page 2 of 12

3 During limited times, when all available resources are in use, JHAAA may be unable to respond and provide complete emergency services to a subscriber or 911 request within its primary ambulance coverage area. Examples of these circumstances are basic or advanced life support treatment (including paramedic assists) and/or other emergency transport related services when all available JHAAA resources are already in use. In the event that JHAAA is not available for a request, it will refer the emergency call to the next closet appropriate ambulance service. This list includes, but is not limited to: Clairton EMS Elizabeth Township EMS Tri-Community Ambulance Association Tri-Community South Ambulance Authority Jefferson Hills Area Ambulance Association is responsible for responding to all received emergency requests, 24 hours per day, 365 days a year. During these limited time periods, another ambulance service may be called upon by JHAAA or other emergency dispatch agency to provide mutual aid assistance including basic, advanced life support, or other EMS related services. As JHAAA has no direct control over which mutual aid service will be sent as mutual aid resources, the subscriber may be responsible for payment of certain charges set forth by mutual aid organizations. In order to help reduce subscriber payment liability for mutual aid services, JHAAA has entered into a reciprocity agreement with a certain number of local mutual aid organizations which extend subscription benefits to covered subscribers who may become ill or injured in other local communities including: Brentwood Borough, Baldwin Borough, Carroll Township, City of Clairton, Elizabeth Township, Elizabeth Borough, Monongahela, Munhall Borough, New Eagle Borough, Pleasant Hills Borough, Peters Township, South Park Township, Bethel Park Borough and Rostraver Township. However, please note that subscription reciprocity coverage is not available for all local mutual aid services. Page 3 of 12

4 Subscription coverage also extends to certain types of pre-scheduled Non- Emergency Ambulance Service which is determined to be medically necessary by JHAAA. Non-emergency ambulance service is subject to availability, staffing, scheduling, equipment and other system constraints. Twenty-four (24) hour notice and prior physician authorization may be required. Non-Emergency Transportation by Ambulance JHAAA provides non-emergency transportation via ambulance. Nonemergency transports are non 911 calls that include the following: Transports from a hospital to another destination [home, nursing facility, extended care facility and/or hospital] Transportation from home to doctors offices Transports from home to treatment centers [dialysis, radiation, physical therapy] These services are discretionary and JHAAA WILL NOT perform nonemergency transports if performing these trips will result in no units available to cover the emergency response area. All non-emergency transportation via ambulance are subject to the following: All non-emergency transports must be preauthorized by the requestor s insurance company. It is the responsibility of the requestor to provide necessary documentation that the trip has been authorized. All non-emergency transports via ambulance must have a signed Physician Medical Necessity Form (PMNC) that is completed by the patient s physician or appropriate healthcare representative. These guidelines are available through the Medicare Administration Office. Copies of the form are available through the JHAAA office by dialing (412) To schedule non-emergency transportation, dial (412) Please have your insurance information and Physician Medical Necessity Form ready, along with patient demographics. Page 4 of 12

5 JHAAA strives to be 15 minutes early for all transports from home to treatments. For all discharges from a hospital to another location, JHAAA reserves a one (1) hour window from set pick up time. JHAAA will not perform Non-Emergency Transports via Ambulance to any Emergency Room. All patients requiring transportation to an Emergency Room are to dial 911. If the information provided concludes that the situation is not urgent, JHAAA will respond in a non-emergent manner. JHAAA responses are dictated by 911 dispatch center based on the county medical dispatch program. Wheelchair Van Transportation JHAAA performs Wheelchair Van Transportation per request to the following destinations: Transports from a hospital to another destination [home, nursing facility, extended care facility and/or another hospital] Transportation from home to doctors offices Transports from home to treatment centers [dialysis, radiation, physical therapy] JHAAA will not perform wheelchair van transportation for non-medical reasons, to include, but not limited to: Shopping trips Family functions Recreational activities ROUTINELY, WHEELCHAIR VAN TRIPS ARE NOT COVERED BY INSURANCE AND ARE THE REPONSIBITY OF THE PATIENT. Most Major insurances, to include Medicare, do not authorize payment for wheelchair van trips. Page 5 of 12

6 Stretcher Van Trips / Invalid Coach Stretcher van trips are trips performed for patients that are bedridden, but do not meet medical necessity for ambulance transportation. Otherwise, the patient s physician has not ordered or deemed it necessary for the patient to be monitored by trained staff. JHAAA performs Stretcher Van / Invalid Coach Transportation per request to the following destinations: Transports from a hospital to another destination [home, nursing facility, extended care facility and/or another hospital] Transportation from home to doctors offices Transports from home to treatment centers [dialysis, radiation, physical therapy] JHAAA will not perform Stretcher Van / Invalid Coach Transportation for non-medical reasons, to include, but not limited to: Shopping trips Family functions Recreational activities ROUTINELY, STRETCHER VAN/INVALID COACH TRIPS ARE NOT COVERED BY INSURANCE AND ARE THE REPONSIBITY OF THE PATIENT. Most Major insurances, to include Medicare, do not authorize payment for wheelchair van trips. Page 6 of 12

7 Public Assists. JHAAA will perform public assists as requested. These assists include: Assistance for patients that have fallen to the floor and need help getting up Assistance for patients that need assistance to access their residence. Assists are only available to residents within the primary jurisdiction of JHAAA. [Jefferson Hills, Union Township, Forward Township and West Elizabeth] Membership Benefits Emergency Ambulance JHAAA is required to respond to all emergency requests regardless of membership status. JHAAA will bill for services rendered at time of request. JHAAA will submit all charges to the patient s medical insurance that is provided at time of service. Residents are encouraged to provide current insurance information. From time to time, JHAAA may contact the patient/family to verify insurance information. Deductibles: Co-Pays: Uninsured: JHAAA will minimize deductibles for active members. JHAAA will adjust insurance co-pays for active members. JHAAA will provide a credit of 50% of the total ambulance bill for active members. Insured members that do not possess ambulance coverage: JHAAA will provide a credit of 50% of the total ambulance bill for active members. Page 7 of 12

8 Membership to JHAAA s Annual fund drive will minimize out of pocket expenses. JHAAA will not direct bill members for the following services: Treatment without transport Refusal of services Public assists All non-members will be billed up to $250 for above services per occurrence. Non-Emergency Ambulance JHAAA will submit all charges to the patient s medical insurance that is provided at time of service. Residents are encouraged to provide current insurance information. From time to time, JHAAA may contact the patient/family to verify insurance information. JHAAA will submit all charges to the patient s medical insurance that is provided at time of service. Residents and/or requesting facility are encouraged to provide current insurance information. In addition, A Physician Medical Necessity Form is required in advance on all nonemergency transports. Once JHAAA has successfully billed the patient s insurance, JHAAA will accept the insurance carrier s payment as Payment in FULL so long as the patient is a current subscriber with JHAAA. ALL non-members will be responsible for the entire balance left unpaid by the insurance carrier. If the member has no insurance coverage, JHAAA will completely absorb the cost of one (1) NON-Emergency ambulance transport or care per year. Subsequent trips will be reduced by up to 50% Page 8 of 12

9 Wheelchair Van Transports As described above, most wheelchair van trips are not covered by insurance carriers, if a resident possesses wheelchair van coverage on their insurance policy, tit is the resident s responsibility to provide an authorization number at the time of trip request. JHAAA members will be entitled to the following: 20% off total bill Five (5) loaded miles free All non-members will be responsible for the entire cost of the bill. Stretcher Van/Invalid Coach As described above, most stretcher van/invalid coach trips are not covered by insurance carriers, if a resident possesses stretcher van/invalid coach coverage on their insurance policy; it is the resident s responsibility to provide an authorization number at the time of trip request. JHAAA members will be entitled to the following: 20% off total bill Five (5) loaded miles free All non-members will be responsible for the entire cost of the bill. Page 9 of 12

10 Payments Subscribers agree and understand that JHAAA reserves the right to bill its reasonable and customary charges relating to any and all services rendered to subscribers by JHAAA to any and all available reimbursement sources. The payors of ambulance service may include the subscriber and/or his or her primary and secondary insurance carriers including federal health care programs (excluding Medicaid) and other commercial insurance carriers, as permitted by law, and are responsible for all changes associated with services provided under this subscription program. JHAAA accepts the following methods of payment: Personal checks made payable to JHAAA Visa, Mastercard, Discover and American Express All invoices are net thirty (30) days from time of statement date. Monthly payment arrangements are available by calling our Business Office at (412) Subscribers are also required to fully cooperate with designated billing representatives authorized by JHAAA in their efforts to collect any and all lawful reimbursement associated with the provision of emergency medical services, non-emergency ambulance services or other applicable services rendered by the ambulance service to subscribers. Subscribers are required to furnish any and all insurance numbers, authorizations and other information needed by JHAAA to submit an insurance claim to any and all applicable insurance carriers. Subscribers are required to immediately remit to JHAAA any and all reimbursement immediately upon receipt from any source including commercial or governmental agencies or any other third party insurance carrier or program for services provided under the Terms and Conditions of the subscription program. Subscribers agree to forward to the ambulance service within five (5) days of receipt any and all payments received for services rendered by the ambulance service during the subscription year. Page 10 of 12

11 Subscribers who fail to forward payments received from other sources further agree to be responsible for any and all legal or collection fees incurred by the ambulance service in order to recover any and all reimbursement received by the subscriber related to the provision of subscription related services including all related costs, fees and interest. Subscribers may also be required to notify their insurance carrier(s), their primary care physician or other applicable parties about services rendered by JHAAA in order to obtain authorization for payment of benefits directly to JHAAA. Whenever possible JHAAA will send invoices directly to the insurer or other medical benefits provider. Subscribers receiving ambulance and other related services will be asked to assign all rights and benefits from any applicable insurance program or medical benefits to JHAAA for services rendered throughout the term of the subscription year. Subscribers will be asked to authorize and direct all reimbursement including any and all reimbursement received from any applicable insurer(s) or medical benefits provider(s) to be paid directly to JHAAA. Subscriptions are non-refundable, non-transferable and may be revoked at the sole discretion of JHAAA. The subscription becomes null and void if the subscriber relocates his/her residence to an area which is located outside of the ambulance service coverage area. JHAAA reserves the right to change the content of its subscription terms and conditions, at any time, without prior written notice, to current subscribers. The terms, as established by the JHAAA Board of Directors in accordance with governmental regulations, shall be posted and available in the JHAAA Business Office and online. ASSIGNMENT OF THIRD PARTY PAYMENT TO JHAAA Subject to acceptance of this assignment when ambulance services are rendered, any payment to JHAAA by my insurance company, co-payments and/or deductions will be accepted by JHAAA for the service provided by JHAAA. As part of the consideration for this subscription agreement, I hereby assign to JHAAA all my rights and benefits under my hospitalization and medical insurance or other medical benefits or insurance policies for service rendered to me by or for JHAAA. I authorize and direct my insurer(s) and medical benefits provider(s) to pay directly to JHAAA all sums owed for each Page 11 of 12

12 service rendered to me. When services are rendered I will notify my insurance as required and provide insurance numbers and authorizations needed by JHAAA to bill my insurance. JHAAA will bill the insurer or other medical benefits provider directly. I agree to forward to JHAAA any payments I receive directly for services rendered to me by or for JHAAA. Should said payments be made directly to me and not forwarded to JHAAA, I agree to be responsible for payment of the services rendered by or for JHAAA. JHAAA subscription fee is applied to applicable co-insurance, copayments or deductibles except as required by law or regulation that I may incur for ambulance service rendered by JHAAA not paid by my third party payer. JHAAA agrees to keep all medical/insurance information confidential and will comply with all relevant confidentiality laws protecting the patient s right of privacy. SUBSCRIPTION COVERAGE APPLIES ONLY TO PERSONS WHO UNCONDITIONALLY ACCEPT ALL OF THE TERMS AND CONDITIONS OUTLINED IN THIS AGREEMENT. Page 12 of 12

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