1. Section Modifications

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1 Idah MMIS Prvider Handbk Table f Cntents Transprtatin Services - Ambulance 1. Sectin Mdificatins Transprtatin Services (Ambulance) Intrductin Definitins Emergency Services Nn-Emergency Service Basic Life Supprt (BLS) Advanced Life Supprt (ALS) Level I (Emergency and Nn-Emergency) Advanced Life Supprt (ALS) Level II Hspital Based Nn-Hspital Based Nn-Emergency Medical Transprtatin (NEMT) General Infrmatin and Requirements Overview Imprtant Billing Instructins Licensing Requirements Apprpriate Transprtatin Service Base Rate fr Ambulances Waiting Time and Extra Attendants Multiple Runs in One Day Physician in Attendance Nursing Hme Residents Deceased Participants Requests fr Recnsideratin f PA r Retrspective Review and Authrizatin Denial Request fr Hearing Prir Authrizatin (PA) Rund Trip Trips t Physician s Office Emergency Transprtatin Overview C-Payment fr Nn-Emergency Use f Ambulance Transprtatin Services Ambulance Prcedure Cdes Requests fr Retrspective Review/Authrizatin July 7, 2014 Page i

2 Idah MMIS Prvider Handbk Transprtatin Services - Ambulance 1. Sectin Mdificatins Versin Sectin/ Clumn Mdificatin Descriptin Publish Date SME 6.0 All Published versin 07/07/14 TQD Basic Life Supprt; Advanced Life Supprt Updated reference t IDAPA rule 07/07/14 A Cppinger C Taylr 5.0 All Published versin 04/25/14 TQD C-Payment fr Nn-Emergency Use f Ambulance Transprtatin Services Updated c-payment amunt t $ /25/14 C Taylr Overview Spelled ut prir authrizatin in first paragraph 04/25/14 C Taylr Nn-Emergency Medical Transprtatin Updated link t AMR 04/25/14 A Cppinger C Taylr 4.0 All Published versin 10/25/13 TQD Changed ICF/MR t ICF/ID 10/25/13 H McCain 3.0 All Published versin 10/20/11 TQD Emergency Transprtatin Prviders Added sectin per DHW request 10/20/11 R Ssin 2.0 All Published versin 08/30/10 TQD 1.2 All Updated sectins fr clarity and ease f use 1.1 All Updated numbering fr sectins t accmmdate Sectin Mdificatins 1.0 All Initial dcument Published versin 08/30/10 T Kinzler 08/30/10 C Stickney 05/07/10 Mlina/TQD July 7, 2014 Page 1 f 11

3 Idah MMIS Prvider Handbk Transprtatin Services - Ambulance 2. Transprtatin Services (Ambulance) 2.1. Intrductin This dcument cvers all ambulance transprtatin services. It als addresses the fllwing prcesses. C-payments Prir authrizatin (PA) prcedures Recnsideratin requests and the appeals prcess 2.2. Definitins Emergency Services Medical necessity is established when the participant s cnditin is f such severity that use f any ther mde f transprt wuld endanger the participant s life r health. An emergency exists when the severity f the medical situatin is such that the usual PA prcedures are nt pssible because the participant requires immediate medical attentin. See sectin Base Rate fr Ambulances, fr a descriptin f ambulance levels f care Nn-Emergency Service Medicaid defines a nn-emergency ambulance service as ambulance transprt, which is medically necessary due t the medical cnditin f the participant, when any ther frm f transprtatin will place the participant s life r health in serius jepardy. This includes inter-facility transfers, nursing hme t hspital transfers, and transfers t the participant s hme frm the hspital. All scheduled, nn-emergency ambulance transprts must be apprved prir t the transprt Basic Life Supprt (BLS) BLS includes all acts and duties that may be perfrmed by a certified Emergency Medical Technician - Basic (EMT-B). The care may be prvided by persnnel with a higher level f certificatin (e.g. advanced EMT-A, EMT-paramedic, registered nurse), but if the care prvided falls within the scpe f practice fr the EMT-B, the level f reimbursement is BLS. Cmmn examples include patient assessment, bleeding cntrl, spinal immbilizatin, and the use f xygen and splints. Fr a cmplete list f the skills and duties allwed fr an EMT-B, refer t the Bard f Medicine Rules fr EMS persnnel. Fr a cmplete list f the skills and duties allwed, refer t IDAPA Emergency Medical Services (EMS) - Agency Licensing Requirements Advanced Life Supprt (ALS) Level I (Emergency and Nn-Emergency) ALS Level I emergency and nn-emergency includes the transprtatin by ambulance and the prvisin f at least ne medically necessary ALS interventin r treatment. An ALS interventin is a prcedure that is beynd the scpe f practice f an EMT-B. Cmmn examples include peripheral venus puncture, electrcardigram (EKG) rhythm interpretatin, and administratin f varius medicatins used in medical, respiratry, r behaviral emergencies. Fr a cmplete list f the skills and duties allwed, refer t IDAPA Emergency Medical Services (EMS) - Agency Licensing Requirements. July 7, 2014 Page 2 f 11

4 Idah MMIS Prvider Handbk Transprtatin Services - Ambulance Advanced Life Supprt (ALS) Level II ALS Level II includes the transprtatin by ambulance and the medically necessary administratin f at least three separate administratins f ne r mre medicatins by intravenus push/blus r cntinuus infusin r ne f the fllwing medically necessary treatments. Manual defibrillatin/cardiversin Endtracheal intubatin Central venus line Cardiac pacing Chest decmpressin Surgical airway Intrasseus line Hspital Based Only ambulances that are wned r leased, and perated by a hspital are designated by Idah Medicaid as hspital based Nn-Hspital Based Only ambulances that are NOT wned r leased, and perated by a hspital are cnsidered nn-hspital based Nn-Emergency Medical Transprtatin (NEMT) NEMT is transprtatin required fr a Medicaid participant t access medically necessary services cvered by Medicaid when the participant s wn transprtatin resurces, family transprtatin resurces, r cmmunity transprtatin resurces d nt allw the participant t reach thse services. Medicaid s NEMT benefit des nt include any ambulance services. Effective September 1st, 2010, Idah Medicaid cntracts with American Medical Respnse (AMR) fr all nn-emergency medical transprtatin services. Please g t r call 1(877) fr mre infrmatin General Infrmatin and Requirements Overview Ambulance services are payable by Medicaid nly if used in the event f a medical emergency r after prir authrizatin (PA) has been btained frm Medicaid Ambulance Review. Medicaid Ambulance Review manages ambulance transprtatin services, including PA f nn-emergency ambulance transprtatin and medical review f emergency ambulance claims. Ambulance services must be medically necessary, as determined by Medicaid Ambulance Review, in rder t be paid by Medicaid. See the Hspital guidelines fr mre infrmatin. July 7, 2014 Page 3 f 11

5 Idah MMIS Prvider Handbk Transprtatin Services - Ambulance Imprtant Billing Instructins Payment Medicaid transprtatin prviders will be reimbursed at the current rate established by DHW r the actual cst f the service, whichever is less Claim Frms Nn-hspital based ambulance prviders may bill electrnically r n the CMS-1500 claim frm. Hspital based ambulance prviders may bill electrnically r n the UB04 claim frm. Frms are available frm lcal frm suppliers. Required attachments include third party payer Explanatin f Benefits (EOB) fr payments r denials Custmary Fees Ambulance service charges t Medicaid cannt exceed the prvider s charges t the public fr the same service (usual and custmary fee). Reimbursement fr nn-hspital based ambulance service is at the rate established by Idah Medicaid. Transprtatin f nursing hme r Intermediate Care Facility fr the Intellectually Disabled (ICF/ID) residents is the respnsibility f the facility unless the medical cnditin f the participant requires ambulance transprt. All nn-emergency ambulance transprts must be prir authrized by Medicaid Ambulance Review Payment in Full The claimant s certificatin (reverse side f the CMS claim frm), signed n each claim submitted fr payment, indicates the Medicaid payment fr the charges n that claim will be accepted as payment in full fr the services rendered. The participant is nt respnsible fr the unpaid balance remaining n cvered services, and shuld nt be billed Medicare Participants If a participant has Medicare cverage, the prvider must first bill Medicare fr services rendered. See General Billing Instructins, Third Party Recvery (TPR), fr billing instructins Submitting Claims t Idah Medicaid The prvider s claim must match the authrized services n the Ntice f Decisin fr Medical Benefits r the claim will be denied. Cntact Medicaid Ambulance Review with questins, pertaining t the review f ambulance claims. Medicaid Ambulance Review PO Bx Bise, ID (208) r 1 (800) Cvered Services Fr nn-hspital based ambulance services, see CMS 1500 Instructins fr cvered services. Fr hspital based ambulance services, see UB04 Instructins fr cvered services. July 7, 2014 Page 4 f 11

6 Idah MMIS Prvider Handbk Transprtatin Services - Ambulance Dates f Service Dates f service must be within the Sunday thrugh Saturday calendar week within a single detail line n the claim. The calendar week begins at 12:00 a.m. n Sunday and ends at 11:59 p.m. n Saturday. Cnsecutive dates f service that fall in ne calendar week (Sunday thrugh Saturday) can be billed n ne claim detail line Emergency Transprtatin Prviders Effective fr claims with dates f service n and after January 1, 2011, ambulance prviders and suppliers must reprt mileage units runded up t the nearest tenth f a mile fr all claims (except hard cpy billers that use the UB-04) fr mileage ttaling less than 100 cvered miles. Prviders and suppliers must submit fractinal mileage using a decimal in the apprpriate place (e.g., 99.9). Fr trips ttaling 100 miles and greater, suppliers must cntinue t reprt mileage runded up t the nearest whle number mile (e.g., 999). Fr mileage ttaling less than ne mile, prviders and suppliers must include a 0 prir t the decimal pint (e.g., 0.9). Example: A prvider transprts a participant every day frm Friday the 10 th t Tuesday the 14 th. Enter the date f service Friday the 10 th t Saturday the 11 th n the first detail line. Enter the date f service Sunday the 12 th t Tuesday the 14 th n the secnd detail line. Example: A prvider transprts a participant n the 10 th, 14 th, and 16 th. Enter each date n a separate detail line Licensing Requirements Medicaid ambulance service prviders must hld a current license issued by the Emergency Medical Services (EMS) Bureau and must cmply with the rules gverning EMS services. Ambulance services based utside the State f Idah must hld a current license issued by that state s EMS licensing authrity. Emergency Medical Services (EMS) Bureau 1 (208) Fax 1 (208) Apprpriate Transprtatin Service Air Ambulance Medicaid cvers air ambulance services when ne f the fllwing ccurs: The pint f pickup is inaccessible by a land vehicle. Great distances r ther bstacles are invlved in getting the participant t the nearest apprpriate facility and urgent medical care is needed. The participant s cnditin and ther circumstances necessitate the use f air ambulance. If grund ambulance services wuld suffice and be less cstly, payment is based n the amunt that wuld be paid fr a grund ambulance. July 7, 2014 Page 5 f 11

7 Idah MMIS Prvider Handbk Transprtatin Services - Ambulance Air ambulance must be apprved by Medicaid Ambulance Review in advance, except in emergency situatins. Nn-hspital based air ambulance services must be billed n the CMS-1500 claim frm, using HCPCS cdes. Only air ambulances that are wned r leased, and perated by a hspital are designated by Idah Medicaid as hspital based. The services must be billed n a UB-04 claim frm using revenue cdes frm the Hspital guidelines Grund Ambulance Nn hspital-based, grund ambulance services must be billed n a CMS-1500 claim frm using HCPCS prcedure cdes. Ambulances that are wned r leased, and perated by a hspital are designated as hspital based. Thse services must be billed n a UB-04 claim frm using revenue cdes fund in the Hspital guidelines Base Rate fr Ambulances Levels f Service Prviders may reprt ne f the fllwing levels f service fr transprting Medicaid participants. Prviders may als request payment fr treat and release r respnd and evaluate if the patient is nt transprted. The three levels f service are: Basic Life Supprt (BLS) (emergency and nn-emergency) Advanced Life Supprt (ALS) I (emergency and nn-emergency) Grund specialty (abve the level f Paramedic) ALS II (emergency and nn-emergency) When reviewing and authrizing a particular level f service, Medicaid Ambulance Review must cnsider if: The requested level f service is equal t r belw the level f EMS certificatin f the persnnel prviding care in the patient cmpartment f the vehicle. The certificatin level f the prvider is dcumented n the patient care recrd. The type f care prvided crrespnds with the level f service requested. Each level f service crrespnds with the Idah Administrative Cde acts and duties allwed fr the pre-hspital care prviders, as per IDAPA Pre-Hspital Advanced Life Supprt (ALS) Standards. Separate fees are nt allwed fr cmpnents f Basic Life Supprt (BLS) r Advanced Life Supprt (ALS) care, such as starting IVs and administering xygen. This includes all nndispsable equipment used in the treatment such as backbards, scp stretchers, and cervical cllars. Dispsable (cnsumable) equipment and medicatins are included in the base rate payment fr grund ambulance services and may nt be billed separately Waiting Time and Extra Attendants Waiting time and extra attendants are nt paid unless medically necessary and authrized by Medicaid Ambulance Review. Waiting time must be physician rdered. July 7, 2014 Page 6 f 11

8 Idah MMIS Prvider Handbk Transprtatin Services - Ambulance Multiple Runs in One Day When the ambulance transprts a participant, returns t the base statin, and transprts the participant a secnd time n the same date, tw base rate payments and laded mileage are allwed. Use mdifier 76 n the secnd prcedure cde t prevent denials fr duplicate claims. When the ambulance transprts a participant, the participant is transferred t anther facility, and the ambulance des nt return t the base statin, ne base rate, waiting time, and laded mileage are allwed Physician in Attendance When a physician is in attendance, the dcumentatin shuld justify the necessity and specialty type f the physician. The physician is respnsible fr the billing f their services Nursing Hme Residents Ambulance services are cvered nly in an emergency situatin r when prir authrized by Medicaid Ambulance Review. Payment fr any nn-cvered, nn-emergency service is the respnsibility f the facility and ambulance prviders may nt bill Medicaid Deceased Participants Ambulance service fr deceased participants is cvered when dcumented in the run sheet as fllws If the participant was prnunced dead after the ambulance was called but befre pickup, a base rate will be allwed. If the participant was prnunced dead while in rute t r upn arrival at the hspital, a base rate and mileage will be allwed. If the participant was prnunced dead by an authrized persn befre the ambulance was called, n payment will be made Requests fr Recnsideratin f PA r Retrspective Review and Authrizatin Denial Prviders may request a recnsideratin f a PA decisin made by DHW, by fllwing these steps. Step 1 Carefully examine the Ntice f Decisin fr Medical Benefits t ensure that the requested services and prcedure cdes were actually denied. Occasinally a requested service/prcedure cde has been denied and the apprpriate service/prcedure cde was actually apprved n the next line in the ntice. Step 2 If yu disagree with the DHW decisin, yu can cmplete a written Request fr Recnsideratin, which is fund n the secnd page f the Ntice f Decisin. Include any additinal extenuating circumstances and specific infrmatin that will assist the authrizing agent in the recnsideratin review. Attach a cpy (frnt and back) f the Ntice f Decisin fr Medical Benefits. July 7, 2014 Page 7 f 11

9 Idah MMIS Prvider Handbk Transprtatin Services - Ambulance Step 3 Submit the written request directly t Medicaid Transprtatin (MT) within 28 calendar days f the mailing date, n the Ntice f Decisin fr Medical Benefits. Medicaid transprtatin will review the additinal infrmatin and return a secnd Ntice f Decisin fr Medical Benefits t the requestr within five wrking days f receipt f the prvider s Request fr Recnsideratin. If the recnsidered decisin is still cntested, the prvider may then submit a written request fr a cntested case hearing. Medicaid participants may request a fair hearing. The Ntice f Decisin fr Medical Benefits includes instructins fr prviders and participants t file a cntested case r fair hearing. Step 4 Maintain cpies (frnt and back) f all dcuments in yur recrds fr a perid f five years Request fr Hearing Step 1 Prepare a written request fr a hearing which must include: A cpy f the Ntice f Decisin fr Medical Benefits n which the prvider requested the recnsideratin. A cpy f the Request fr Recnsideratin letter frm MT, which upheld the denial. Cpies f any additinal supprting dcumentatin which shuld be cnsidered at a hearing. Step 2 Mail r fax the infrmatin t Idah Department f Health and Welfare Hearings, Medicaid Transprtatin PO Bx Bise, ID Fax 1 (208) Medicaid Transprtatin (MT) will submit all dcumentatin t the hearing fficer, wh will schedule a hearing. Cntact MT with any questins abut the Ntice f Decisin fr Medical Benefits, the recnsideratin decisin, r the appeal prcess Prir Authrizatin (PA) Obtaining Prir Authrizatin (PA) Please nte that ALL transprts must receive prir authrizatin BEFORE the actual transprt. T btain prir authrizatin fr nn-emergency ambulance services: Make the request a minimum f 24 hurs befre any scheduled appintment time. Allw fr weekends and state hlidays. July 7, 2014 Page 8 f 11

10 Idah MMIS Prvider Handbk Transprtatin Services - Ambulance Call ur Medical Prgram Specialist tll free at 1 (800) r in the Bise area at 1 (208) Yu will need t prvide the fllwing infrmatin. Participant name, date f birth, and Medicaid ID number Whether r nt the participant has Medicare r ther insurance Transfer date and time Level f service BLS, ALS, Spec/Ne Pick up pint and destinatin Discharging physician and receiving physician Admit date and diagnsis Medical reasn fr transprt FAX the fllwing t 1 (877) Histry and physical Prgress reprts Discharge summary (if available) Other infrmatin that may be needed fr physician review f medical necessity After hurs, if there are any questins r further infrmatin that may be needed, please call and leave all the infrmatin n the vic , alng with a return name and phne number. After a request fr PA has been submitted t DHW s authrizing agent r designee, DHW will initiate a Ntice f Decisin fr Medical Benefits t the participant and the transprtatin prvider indicating which prcedures are authrized r denied. The prcedure cdes authrized n the ntice must match the prcedure cdes billed n the claim frm Rund Trip Medicaid places restrictins n rund-trip charges, depending n whether the ambulance returns t the base statin between trips. When the ambulance des nt return t base statin, bill fr ne base rate, rund-trip laded miles, and waiting time (limited t ne and ne-half hurs). When the ambulance des nt wait but returns t the base statin between trips, bill fr tw base rates and laded rund-trip mileage Trips t Physician s Office Ambulance service frm a participant s hme t a physician s ffice is nt cvered unless prir authrized by Medicaid Ambulance Review Emergency Transprtatin Overview All prvider claims fr ambulance services must be reviewed and authrized as medically necessary and apprpriate by Medicaid Ambulance Review befre Medicaid will reimburse the ambulance prvider Treat and Release A treat and release payment may be authrized if the participant is treated at the scene and nt transprted. Dispsable supplies are included in the treat and release payment. Treat and release may be requested at the BLS r ALS level, depending n the treatment July 7, 2014 Page 9 f 11

11 Idah MMIS Prvider Handbk Transprtatin Services - Ambulance prvided. See sectin Base Rate fr Ambulances fr details n determining the apprpriate level f service. Medicaid Ambulance Review may dwngrade a claim t a treat and release payment if the participant was transprted but the transprt is determined t nt be medically necessary. N mileage will be paid Respnd and Evaluate A respnd and evaluate payment may be authrized if the ambulance respnds t the scene and evaluates the participant, but treatment r transprt is nt necessary. Medicaid Ambulance Review may dwngrade a claim t a respnd and evaluate payment if the participant was transprted, but the transprt is determined t nt be medically necessary. N mileage, supplies, nr ther services will be paid in additin t payment fr respnd and evaluate C-Payment fr Nn-Emergency Use f Ambulance Transprtatin Services Idah Medicaid implemented c-payment prvisins f Huse Bill #663 passed by the 2006 Idah legislature. Ambulance prviders may bill Medicaid participants a $3.65 (three dllar and sixty-five cent) c-payment fr inapprpriate ambulance service utilizatin when the fllwing cnditins are met. The Department f Health and Welfare (DHW) determines that the Medicaid participant s medical cnditin did nt require emergency ambulance transprtatin. DHW determines the Medicaid participant is nt exempt frm making c-payments accrding t Federal statute. DHW will ntify bth the ambulance prvider and the Medicaid participant n the Ntice f Decisin letter when a participant may be billed fr a c-payment. Nte: Cllectin f the c-payment is at the discretin f the prvider and is nt required by Idah Medicaid Ambulance Prcedure Cdes All ambulance services by a nn-hspital based ambulance shuld be billed n a CMS-1500 claim frm r submitted electrnically using the fllwing HCPCS cdes. It is nt necessary t attach the run sheet t the claim. Payment fr ambulance transprt is fr a ne way trip in which the participant is in the patient cmpartment f the vehicle, except when a rund trip is authrized by Medicaid Ambulance Review Requests fr Retrspective Review/Authrizatin T btain a retrspective authrizatin fr emergency services and transprtatin, fax r mail a cpy f the cmpleted claim frm and patient care recrd t the Medicaid Ambulance Review. Attach a cpy f the third party EOB if applicable. Upn receipt f the cmpleted claim infrmatin: The level f service requested by the prvider is evaluated. The level f service billed cannt exceed the level f EMS certificatin unless the persnnel prviding care in July 7, 2014 Page 10 f 11

12 Idah MMIS Prvider Handbk Transprtatin Services - Ambulance the patient cmpartment have a higher level f certificatin than the ambulance license. The claim is evaluated fr apprpriate mileage. Dispsable supplies are included in the base rate payment and may nt be billed separately. Any ptential denial r dwngrade f the requested service is reviewed by a Medical Transprtatin Specialist and may be referred t the Medical Directr fr review prir t the denial r dwngrade. An apprved r denied decisin is submitted t Idah Medicaid and a Ntice f Decisin fr Medical Benefits is generated t the participant and the ambulance prvider. The Ntice f Decisin will include a PA number, prcedure cdes, dates f service, and number f units necessary fr billing. Questins regarding Ntice f Decisin fr Medical Benefits shuld be directed t Medicaid Ambulance Review at: Ambulance: Emergency Transprt 1(208) r 1(800) July 7, 2014 Page 11 f 11