Subject: Transportation Services: Ambulance and Non-Emergent Transport

Transcription

1 Anthem BlueCrss BlueShield Medicaid Reimbursement Plicy Subject: Transprtatin Services: Ambulance and Nn-Emergent Transprt Effective Date: 08/18/14 Cmmittee Apprval Obtained: 08/18/14 Sectin: Transprtatin These plicies serve as a guide t assist yu in accurate claims submissins and t utline the basis fr reimbursement by Anthem Blue Crss and Blue Shield Medicaid (Anthem) if the service is cvered by a member s benefit plan. The determinatin that a service, prcedure, item, etc. is cvered under a member's benefit plan is nt a determinatin that yu will be reimbursed. Services must meet authrizatin and medical necessity guidelines apprpriate t the prcedure and diagnsis as well as t the member s state f residence. Yu must fllw prper billing and submissin guidelines. Yu are required t use industry-standard, cmpliant cdes n all claim submissins. Services shuld be billed with CPT cdes, HCPCS cdes and/r revenue cdes. The cdes dente the services and/r prcedures perfrmed. The billed cde(s) are required t be fully supprted in the medical recrd and/r ffice ntes. Unless therwise nted within the plicy, ur plicies apply t bth participating and nnparticipating prviders and facilities. If apprpriate cding/billing guidelines r current reimbursement plicies are nt fllwed, Anthem may: Reject r deny the claim Recver and/r recup claim payment Anthem s reimbursement plicies are develped based n natinally accepted industry standards and cding principles. These plicies may be superseded by mandates in prvider, state, federal, r Centers fr Medicare & Medicaid Services (CMS) cntracts and/r requirements. System lgic r setup may prevent the lading f plicies int the claims platfrms in the same manner as described; hwever, Anthem strives t minimize these variatins. Anthem reserves the right t review and revise ur plicies peridically when necessary. When there is an update, we will publish the mst current plicy t this site. Plicy Anthem allws reimbursement fr transprt t and frm cvered services r ther services mandated by cntract unless prvider, state, federal, r CMS cntracts and/r requirements indicate therwise. Reimbursement is based n the guidelines in this plicy. Due t the cmplex nature f transprtatin services, Anthem recmmends that prviders als review state guidelines fr cverage requirements. Nn-Emergent Transprt Services Nn-Emergency Medical Transprt (NEMT) entails the transprt f a member by nnmedically skilled persnnel (laypersns) t receive cvered services. There are several types f medical transprts: ambulette/medi-van, wheelchair van, invalid cach, taxicab, mini-bus, and public transprtatin (bus and/r subway). Anthem Blue Crss and Blue Shield Medicaid is the trade name f Anthem Kentucky Managed Care Plan, Inc., independent licensee f the Blue Crss and Blue Shield Assciatin. ANTHEM is a registered trademark f Anthem Insurance Cmpanies, Inc. The Blue Crss and Blue Shield names and symbls are registered marks f the Blue Crss and Blue Shield Assciatin. WEB-AKY Octber 2014

2 Anthem Blue Crss Blue Shield Medicaid Transprtatin Services: Ambulance and Nn-Emergent Transprt Page 2 f 5 In sme instances, NEMT services are prvided thrugh a state vendr nt Anthem. Reimbursement fr medical transprt services is based n receipt f a claim r an invice frm cntracted transprtatin vendrs r ther suppliers detailing: The nnemergency medical transprt base rate per trip, where a trip is defined by the rigin and destinatin mdifiers. Mileage Parking and/r tll fees. Ambulance Services Reimbursement fr ambulance services is based n: The ambulance base rate per trip in accrdance with the medically necessary level f care prvided t the member, where a trip is defined by the rigin and destinatin mdifiers. The fee schedule r cntracted/negtiated rate fr services and items is separately reimbursable frm the ambulance base rate. If ambulance transprt is medically necessary fr inpatient-t-inpatient transfer between hspital-based facilities, reimbursement is included in the inpatient stay. Included in the Ambulance Base Rate Services reimbursed as part f the ambulance base rate: Ambulance equipment and supplies: Dispsable/first aid supplies Reusable devices/equipment Oxygen Intravenus (IV) drugs Ambulance persnnel services Separately Reimbursable frm the Ambulance Base Rate Services that are nt part f the ambulance base rate are separately reimbursable expenses: Mileage Additinal apprpriately licensed medical persnnel as medically necessary fr member s health status. Unusual waiting time (in excess f thirty [30] minutes). Dispsable/first aid supplies in greater than nrmal use. Transprtatin Mdifiers Claims fr transprtatin services must be billed with the fllwing rigin and destinatin mdifiers. Claims fr transprtatin services submitted withut rigin and destinatin mdifiers will be denied. Mdifier D: Diagnstic r therapeutic site/free-standing facility ther than

3 Anthem Blue Crss Blue Shield Medicaid Transprtatin Services: Ambulance and Nn-Emergent Transprt Page 3 f 5 P r H Mdifier E: Residential, dmiciliary, custdial facility (fr example nursing hme, nt a skilled nursing facility) Mdifier G: Hspital-based dialysis facility (hspital r hspitalassciated) Mdifier H: Hspital (inpatient r utpatient) Mdifier I: Site f transfer (fr example airprt r helicpter pad) between types f ambulance Mdifier J: Nnhspital-based dialysis Mdifier N: Skilled Nursing Facility (SNF) including swing bed Mdifier P: Physician s ffice including HMO nnhspital facility, clinic, etc. Mdifier R: Private residence Mdifier S: Scene f accident r acute event Mdifier X: Intermediate stp at the physician s ffice en rute t hspital (includes HMO nnhspital facility, clinic, etc.) Mdifier X can nly be used as a destinatin cde in the secnd psitin f a mdifier. In additin t the rigin and destinatin mdifiers, the fllwing mdifiers are t be used when apprpriate: Mdifier GM: Indicates multiple members n ne trip Mdifier QL: Indicates the member died after the ambulance was called Mdifier QM: Indicates the prvider arranged fr the transprtatin services Mdifier QN: Indicates the prvider furnished the transprtatin services Mdifier TK: Indicates multiple carry trips Mdifier TQ: Indicates life supprt transprt by a vlunteer ambulance prvider Mdifiers fr transprtatin f prtable/mbile radilgy equipment Nnreimbursable Anthem des nt allw reimbursement f the fllwing fr any ambulance r medical transprt service prvided: A member wh is nt available (n-shw). Additinal rates fr night, weekend, and/r hliday calls. Mileage in transit t pick up r drp ff the member (unladed mileage). Mileage fr additinal passengers. Mileage fr extra attendant fr additinal passengers. Mileage when the transprt service has been denied r is nt cvered. Transprt fr a member s r caregiver s cnvenience. Transprt available free f charge. Fr ambulance services nly:

4 Anthem Blue Crss Blue Shield Medicaid Transprtatin Services: Ambulance and Nn-Emergent Transprt Page 4 f 5 Fr reasns ther than medical care. Where anther means f transprtatin (fr example medi-van, public transprtatin) culd be used withut endangering the member s health. Fr separate reimbursement fr services/items included in the base ambulance rate. Fr a higher level f care when a lwer level is mre apprpriate (advanced life supprt [ALS] service when basic life supprt [BLS] is apprpriate). Fr bth basic and advanced life supprt when ALS services are prvided. Fr services prvided by the emergency medical technician (EMT) in additin t ALS r BLS base rates. Fr services prvided n the ambulance by hspital staff. Additinal grund and/r air ambulance prviders that respnd but d nt transprt the member. Transprt frm the member s hme t a facility ther than a hspital, skilled nursing facility, dialysis facility, r nursing hme. Transprt frm a facility ther than a hspital, skilled nursing facility, dialysis facility, r nursing hme t the member s hme. Transprt f persns ther than the member and a medically required attendant wh d nt require medical attentin. Transprt fr a member prnunced dead prir t the grund and/r air ambulance being cntacted. Mileage beynd the nearest apprpriate facility (excessive mileage). Fr medical transprt services nly: Transprtatin vendr/supplier ldging r meals. Vehicle maintenance r gas. Histry References and research materials Definitins Anthem review apprved and effective 08/18/14 Anthem review apprved and effective 01/01/14 This plicy has been develped thrugh cnsideratin f the fllwing: CMS Kentucky Medicaid Anthem state cntract Optum Learning: Understanding Mdifiers, 2014 editin Ambulance Services Ambulance services entail the medically necessary transprt f a member by medically skilled persnnel t the nearest apprpriate facility equipped t prvide care fr the member s injury and/r illness. Services are initially delineated as basic life supprt (BLS) r advanced life supprt (ALS) levels f care and then further delineated as emergency r nn-emergency: BLS cnsists f nninvasive services prvided by persnnel

5 Anthem Blue Crss Blue Shield Medicaid Transprtatin Services: Ambulance and Nn-Emergent Transprt Page 5 f 5 trained as an EMT (basic) in cnjunctin with applicable state laws. ALS cnsists f invasive services prvided by persnnel trained as EMTs (intermediate r paramedic) in cnjunctin with applicable state laws. Emergency ambulance transprtatin is an urgent service in which the member experiences a sudden, unexpected nset f acute illness r injury requiring immediate medical r surgical care which the member secures immediately after the nset, (r as sn thereafter as practical) and, if nt immediately treated, culd result in death r permanent impairment t the member s health. Nnemergency ambulance transprtatin is a scheduled r unscheduled service in which the member requires attentin by EMT-trained persnnel while in transit. Ambulance Types There are tw types f ambulance transprts: Grund ambulance An equipped and staffed land r water vehicle designed t transprt a member in the supine psitin. Air ambulance An equipped and staffed aircraft necessary t rapidly transprt a member t the nearest apprpriate facility that culd nt therwise be accmplished r be accessed by a grund ambulance withut endangering the member s health. Air ambulances are either rtary-wing (helicpter) r fixed-wing (cmmercial r private aircraft). Medical Transprt Services Medical Transprt Services, als referred t as nn-emergency medical transprt (NEMT), entails the transprt f a member by nnmedically skilled persnnel (laypersns) t receive cvered services. There are several types f medical transprts: ambulette/medi-van, wheelchair van, invalid cach, taxicab, mini-bus, and public transprtatin (bus and/r subway). Transprtatin Mdifiers: Single alpha characters with distinct definitins that are paired tgether t frm a tw-character mdifier; the first character indicates the riginatin f the member, and the secnd character indicates the destinatin f the member. General Reimbursement Plicy Definitins Related plicies Prtable/Mbile Handheld Radilgy Services Related materials Nne