KANSAS MEDICAL ASSISTANCE PROGRAM PROVIDER MANUAL. Ambulance

Transcription

1 KANSAS MEDICAL ASSISTANCE PROGRAM PROVIDER MANUAL Ambulance

2 PART II Introduction Section BILLING INSTRUCTIONS Page 7000 Ambulance Billing Instructions Submission of Claim BENEFITS AND LIMITATIONS 8100 Copayment Benefit Plans Medicaid Appendix Codes A-1 FORMS All forms pertaining to this provider manual can be found on the public website at and on the secure website at CPT codes, descriptors, and other data only are copyright 2009 American Medical Association (or such other date of publication of CPT). All rights reserved. Applicable FARS/DFARS apply. Information on the American Medical Association is available at

3 PART II Updated 11/09 This is the provider specific section of the manual. This section (Part II) was designed to provide information and instructions specific to ambulance providers. It is divided into three subsections: Billing Instructions, Benefits and Limitations, and Appendix. The Billing Instructions subsection gives an example of the billing form applicable to ambulance services. The form is followed by directions for completing and submitting the billing form applicable to ambulance services it. The Benefits and Limitations subsection defines specific aspects of the scope of ambulance services allowed within the KHPA Medical Plans. The Appendix subsection contains information concerning procedure codes. The appendix was developed to make finding and using procedure codes easier for the biller. HIPAA Compliance As a participant in the KHPA Medical Plans, providers are required to comply with compliance reviews and complaint investigations conducted by the Secretary of the Department of Health and Human Services as part of the Health Insurance Portability and Accountability Act (HIPAA) in accordance with section 45 of the code of regulations parts 160 and 164. Providers are required to furnish the Department of Health and Human Services all information required by the Department during its review and investigation. The provider is required to provide the same forms of access to records to the Medicaid Fraud and Abuse Division of the Kansas Attorney General's Office upon request from such office as required by K.S.A and amendments thereto. A provider who receives such a request for access to or inspection of documents and records must promptly and reasonably comply with access to the records and facility at reasonable times and places. A provider must not obstruct any audit, review or investigation, including the relevant questioning of employees of the provider. The provider shall not charge a fee for retrieving and copying documents and records related to compliance reviews and complaint investigations. i

4 7000. AMBULANCE BILLING INSTRUCTIONS Updated 11/09 Introduction to the CMS-1500 Claim Form Ambulance providers must use the CMS-1500 red claim form (unless submitting electronically) when requesting payment for medical services and supplies provided under the KHPA Medical Plans. Any claim not submitted on the red claim from will be returned to the provider. The Kansas MMIS will be using electronic imaging and optical character recognition (OCR) equipment. Therefore, information will not be recognized if not submitted in the correct fields as instructed. Complete, line-by-line instructions for completion of the CMS-1500 are available in Section 5800 of the General Billing Provider Manual. An example of the CMS-1500 claim form is on the public website at and on the secure website at in the forms section at the end of this manual. The fiscal agent does not furnish the CMS-1500 claim form to providers. Refer to the Form Reordering section of the General Billing Provider Manual. SUBMISSION OF CLAIM Send completed first page of each claim and any necessary attachments to: KHPA Medical Plans Office of the Fiscal Agent P.O. Box 3571 Topeka, Kansas

5 BENEFITS AND LIMITATIONS COPAYMENT Updated 11/09 Nonemergency ambulance transportation requires a copayment from the beneficiary of $3 per date of service. When procedure A0426 or A0428 is billed in conjunction with one of the other nonemergency procedure codes (such as S0215) for the same dates of services, copayment will be collected from the beneficiary only once. Bill all services occurring on the same date on the same claim form. If multiple claims are submitted for the same date(s) of service, the $3 copayment requirement will be deducted for each claim submitted. Do not reduce the charges or balance due by the copayment amount. This reduction will be made automatically during claim processing. 8-1

6 BENEFITS AND LIMITATIONS Benefit Plan Updated 11/09 KMAP beneficiaries will be assigned to one or more benefit plans. These benefit plans entitle the beneficiary to certain services. If there are questions about service coverage for a given benefit plan, refer to Section 2000 of the General Benefits Provider Manual for information on the plastic State of Kansas Medical Card and eligibility verification. For example, only the following emergency transportation procedure codes are covered under the MediKan program. See Appendix I of the Ambulance Provider Manual for a full listing description of services. A0225 A0380 A0390 A0427 A0429 A0430 A0431 A0433 A0434 A0435 A

7 8400. MEDICAID Updated 11/09 BENEFITS AND LIMITATIONS Benefits Covered Services Emergency ambulance transportation provided by Basic Life Support (BLS)/Advanced Life Support (ALS) services Nonemergency ambulance transportation with the exception of adult care home residents (see page 8-4) for the following: o o o Discharge from hospital to residence or other less expensive care Trips from residence to closest available medically necessary services Trips from one institution to another to receive a medical service not available in the first institution Supplies Waiting Time Limitations The medical condition of the beneficiary must necessitate ambulance transportation. Emergency situations in which services are performed after the providers response to the onset of a medical condition manifested by acute symptoms of sufficient severity that the absence of immediate medical attention could reasonably be expected to result in one of the following: o Place the beneficiary's health in serious jeopardy o Seriously impair bodily functions; or o Result in serious dysfunction of any bodily organ or part Trips that could have been scheduled are not considered emergencies. Nonemergency transportation when the beneficiary's condition is such that a car or van cannot be used, e.g.: o Beneficiary unconscious o Beneficiary cannot sit up o Oxygen or other life support required o Extreme obesity or position of cast(s) o Restraints required 8-3

8 8400. Updated 11/09 Ambulance transportation for a deceased person is covered only if the person was pronounced dead while enroute to or upon arrival at destination. If the person was pronounced dead after the ambulance was called, but before pickup, the service to the point of pickup is covered. When an ambulance responds to a 911 call that is determined upon patient assessment to be nonemergent and the patient is transported, the ambulance provider must bill one of the nonemergency ambulance transportation procedure codes. Emergency 911 calls that do not result in transporting the patient are not covered and may be billed to the patient. Licensing Requirements and Restrictions Ambulance providers must be licensed by the state to provide the level of service for which reimbursement is being requested. Services Requiring Medical Necessity Medical necessity documentation (see Section 4100 of the General Special Requirements Provider Manual) must be attached to the claim form when billing for nonemergency transports, waiting time, multiple patients on one ambulance trip, and air ambulance transportation. When the beneficiary is Kansas Medical Assistance Program (KMAP) eligible plus qualified Medicare beneficiary (QMB), and Medicare allows the service, medical necessity (MN) need not be attached to the claim. However, it must be available in the provider's file. The documentation must be printed and legible. MN for nonemergency ambulance transportation must state the reason the trip is required (hospital discharge or medical service) and the medical reason the beneficiary could not be transported by car or van. MN for air ambulance transportation must indicate the beneficiary's medical condition required immediate and rapid ambulance transportation that could not have been provided by land ambulance and one of the following: The point of pickup is inaccessible by land vehicle. Great distances or other obstacles are involved in getting the beneficiary to the nearest hospital with appropriate facilities. The beneficiary's condition is such that the time needed to transport by land, or the instability of transportation by land, poses a threat to the beneficiary's survival or seriously endangers the beneficiary's health. If a determination is made that transport by ambulance was necessary, however, land ambulance service would have sufficed, payment for the air ambulance service will be the lesser of the billed charges and the maximum allowable for ground ambulance. 8-4

9 8400. Updated 03/08 Air Ambulance Guidelines: Time: If time is a critical factor in the patient s recovery or survival or duration of ground transport would be excessive and potentially detrimental, air transport may be indicated. In general, if the ground ambulance can arrive at the destination institution within 20 minutes, it is the preferred mode of transport. Expertise: If the health care institution does not possess the expertise to provide the definitive care required to stabilize the patient (i.e., advanced life support) and the ground ambulance providers in the near vicinity cannot provide assistance in providing that care, air transport may be indicated. Coverage: If ground ambulance utilization leaves the service area without adequate ground coverage and patient outcome will be compromised by arranging other ground transport, air transport may be indicated. Documentation: The above guidelines serve as a guide to documentation which is necessary to determine proper reimbursement and must specify the indication and justification for air transport. If guidelines are not met, or are met but not documented, the billed transportation will be reimbursed at ground ambulance rates or denied altogether. Services Requiring Prior Authorization: Wheelchair transportation is not considered ambulance transportation and requires prior authorization by the beneficiary's local SRS office (who also bills the service). Transportation of ACH Residents: The cost of transporting a current adult care home resident for nonemergent services (either by ambulance or commercial nonambulance medical transportation) is a responsibility of the nursing facility. This includes new admissions to the nursing facility. The cost of transporting residents and new admissions to the nursing facility is a cost nursing facilities will incur. Transportation Services for Hospice Beneficiaries: Transportation to hospice-related services is the responsibility of the hospice provider. Medical services unrelated to hospice treatment or diagnosis may be covered if medical criteria are met. Medically necessary ambulance transportation services provided to hospice consumers are covered. The coverage requirement for these services is the same as for any Kansas Medical Assistance Program consumer. In the instance that prior authorization (PA) is required, the transportation provider should contact the hospice for any medical information that may be needed to obtain PA. 8-5

10 8400. Updated 11/09 Emergency Medical Services For Aliens (SOBRA) In addition to inpatient hospital and emergency room hospital, emergency services performed in outpatient facilities and related physician, lab, and X-ray services will be allowed for the following places of service: office, outpatient hospital, Federally Qualified Health Clinics, state or local public health clinics, rural health clinics, ambulance, and lab for SOBRA claims. Inpatient hospital reimbursement will not be limited to 48 hours. Follow-up care will not be allowed once the emergent condition has been stabilized. Refer to Section 2040 of the General Benefits Provider Manual for specific information. 8-6

11 CODES Updated 11/09 APPENDIX The following codes represent an all-inclusive list of ambulance services billable to the KHPA Medical Plans. Codes not listed here are considered noncovered. Please use the following resources to determine current coverage and pricing information. For accuracy, use your provider type and specialty as well as the beneficiary ID number or benefit plan. Information from the public website is available at: Information from the secure website is available under Pricing and Limitations at: A chart has been developed to assist providers in understanding how KHPA will handle specific modifiers. The Coding Modifiers chart is available on both the public and secure websites. It is under Reference Codes on the main provider page and Pricing and Limitations on the secure portion. Information on the American Medical Association is available at A0225 A0380 A0390 A0422 A0424 A0427 A0429 A0433 A0434 Medical necessity documentation is required for the following codes: A0420 A0426 A0428 A0430 A0431 A0435 A0436 S0215 Modifier GM can be used with the following procedure codes: A0225 A0427 A0429 A0430 A0431 A0433 A-1