TRANSPORTATION SERVICES

TRANSPORTATION SERVICES ADMINISTRATIVE POLICY Policy Number: TRANSPORT 002.15 T2 Effective Date: March 1, 2015 Table of Contents CONDITIONS OF COVERAGE... BENEFIT CONSIDERATIONS... COVERAGE RATIONALE... DEFINITIONS... APPLICABLE CODES... DESCRIPTION OF SERVICES... REFERENCES... POLICY HISTORY/REVISION INFORMATION... Page 1 2 2 6 6 7 7 8 Related Policy: Members Outside of the United States Emergency Room Visits The services described in Oxford policies are subject to the terms, conditions and limitations of the Member's contract or certificate. Unless otherwise stated, Oxford policies do not apply to Medicare Advantage enrollees. Oxford reserves the right, in its sole discretion, to modify policies as necessary without prior written notice unless otherwise required by Oxford's administrative procedures or applicable state law. The term Oxford includes Oxford Health Plans, LLC and all of its subsidiaries as appropriate for these policies. Certain policies may not be applicable to Self-Funded Members and certain insured products. Refer to the Member's plan of benefits or Certificate of Coverage to determine whether coverage is provided or if there are any exclusions or benefit limitations applicable to any of these policies. If there is a difference between any policy and the Member s plan of benefits or Certificate of Coverage, the plan of benefits or Certificate of Coverage will govern. CONDITIONS OF COVERAGE Applicable Lines of Business/Products Benefit Type Referral Required (Does not apply to non-gatekeeper products) Authorization Required (Precertification always required for inpatient admission) Precertification with Medical Director Review Required Applicable Site(s) of Service (If site of service is not listed, Medical Director review is required) Special Considerations This policy applies to Oxford Commercial plan membership General benefits package No 1, 2, 3 Yes 1, 2, 3 No Ambulance 1 Emergency or 911 land transportation to a hospital and/or hospital emergency facility does not require notification, pre-certification or certification. 2 Precertification with review by a Medical Director or their designee is required for non-emergent transportation (land, air or water). 3 All requests for air or water transportation require precertification with Medical Director review. In the event precertification is not feasible 1

Special Considerations (continued) due to time constraints related to medical emergencies, Oxford will require review of clinical notes post service and prior to payment. BENEFIT CONSIDERATIONS Oxford reserves the right to limit the reimbursement of transportation to the nearest appropriate provider of medical services when traveling farther provides no medical benefit to the Member. The following transportation services are not covered: Transportation for a Member in an acute care facility, to an off-site location for diagnostic or therapeutic services. Transportation from a hospital capable of treating the Member because the Member and/or his family prefer a specific hospital or physician. Extra attendants or extra personnel. Transportation for non-emergency or elective medical services when the Member exits from or is located outside of the Oxford service area. Transportation for Member convenience, for non-clinical reasons or for medical services that can be provided in the home. Non-emergency transportation except for Members meeting the medical necessity criteria listed under above. Ambulette service or other forms of passenger transportation that is available to the public (e.g., buses, taxis or airplanes) Transportation of ambulance staff or other personnel when the patient is not onboard the ambulance (e.g., an ambulance transport to pick up a specialty care unit from one hospital to provide services to a patient at another hospital). Product Specific Information Healthy NY Products Ambulance services are not covered. This service is benefit exclusion under the Member's certificate of coverage. NJ Plans and Products If the member has no choice in what type of emergent transport the emergency personnel determines is necessary, the member must be held harmless (i.e., medical necessity does not have to be demonstrated). Mobile Intensive Care Units must be treated the same as an emergency room visit (cost sharing, notification requirements, etc.). COVERAGE RATIONALE I. Emergency (or 911) Land Transportation Emergency transportation to an acute care hospital and/or hospital emergency facility does not require notification, pre-certification or certification. II. Non-emergency Transportation Oxford covers ambulance/transportation services to the same extent as CMS: only when the Member's medical condition is such that other means of transportation are contraindicated. Precertification is required and the following criteria must be met. The patient must: 1. Be bed-confined and other means or transportation are contraindicated; or 2

2. Have a medical condition that is such that transportation by ambulance is medically necessary. A Member is considered bed-confined* when s/he is unable to: a. Get up from a bed without assistance; and b. Ambulate; and c. Sit in a chair or wheelchair *Note: The term "bed confined" is not synonymous with "bed rest" or "nonambulatory". Bed-confinement, by itself, is neither sufficient nor is it necessary to determine the coverage for transportation benefits. It is simply one element of the patient s condition that may be taken into account in the Oxford s determination of whether means of transport other than an ambulance were contraindicated. For Members not meeting criteria for non-emergent transportation, social workers may be contacted to assist with community resources. III. Medically Necessity Documentation Medical necessity is established when the patient's condition is such that use of any other method of transportation is contraindicated. In any case, in which some means of transportation other than an ambulance could be utilized without endangering the individual's health, whether or not such other transportation is actually available, no payment may be made for the service. In all cases, the appropriate documentation must be kept on file and, upon request, presented to Oxford. In addition, the presence (or absence) of a physician s order for a transport by ambulance does not necessarily prove (or disprove) whether the transport was medically necessary. The transportation service must meet all program coverage criteria in order for payment to be made. Note: Payment for transportation is based on the level of service actually furnished (provided they were medically necessary), not simply on the vehicle used. Even if a local government requires an ALS response for all calls, payment under the FS is made only for the level of service furnished, and then only when the service is medically necessary. IV. Transportation Vehicle and Crew Requirements There are technical specifications required for coverage of transportation services applicable to the vehicle, the crew, documentation, charges: A. The Vehicle: Any vehicle used as an ambulance must be designed and equipped to respond to medical emergencies and, in non-emergency situations, be capable of transporting patients with acute medical conditions. The vehicle must comply with State or local laws governing the licensing and certification of an emergency medical transportation vehicle. At a minimum, the ambulance must contain a stretcher, linens, emergency medical supplies, oxygen equipment, and other lifesaving emergency medical equipment and be equipped with emergency warning lights, sirens, and telecommunications equipment as required by State or local law. This should include, at a minimum, one 2-way voice radio or wireless telephone. B. The Crew: Basic Life Support vehicles must be staffed by at least two people, at least one of whom must be certified as an emergency medical technician (EMT) by the State or local authority where the services are being furnished and be 3

legally authorized to operate all lifesaving and life-sustaining equipment on board the vehicle. Advanced Life Support (ALS) vehicles must be staffed by at least two people, at least one of whom must be certified by the State or local authority as an EMT-Intermediate or an EMT-Paramedic. C. Verification of Compliance: In determining whether the vehicles and personnel of each supplier meet all of the above requirements, Oxford may accept the supplier's statement (absent information to the contrary) that its vehicles and personnel meet all of the requirements if the: 1. Statement describes the first aid, safety, and other patient care items with which the vehicles are equipped, 2. Statement shows the extent of first aid training acquired by the personnel assigned to those vehicles, 3. Statement contains the supplier's agreement to notify carriers such as Oxford of any change in operation which could affect the coverage of his transportation services, and 4. Information provided indicates that the requirements are met. The statement must be accompanied by documentary evidence that the ambulance has the equipment required by State and local authorities. Documentary evidence could include a letter from such authorities, a copy of a license; permit certificate, etc., issued by the authorities. The statement and supporting documentation would be kept on file by Oxford. When a supplier does not submit such a statement or whenever there is a question about a supplier's compliance with any of the above requirements for vehicle and crew (including suppliers who have completed the statement), Oxford (consistent with Medicare) may take appropriate action including, where necessary, on-site inspection of the vehicles and verification of the qualifications of personnel to determine whether the transportation service qualifies for reimbursement. Since the requirements described above for coverage of transportation services are applicable to the overall operation of the transportation supplier's service, it is not required that information regarding personnel and vehicles be obtained on an individual trip basis. D. Equipment and Supplies: As mentioned above, the ambulance must have customary patient care equipment and first aid supplies, including reusable devices and equipment such as backboards, neck boards, and inflatable leg and arm splints. These are all considered part of the general transportation service and payment for them is included in the payment rate for the transport. V. Documentation Requirements: For All Transportation: Point of pick-up must be documented for claim to be processed for payment. Non-emergency Transportation: The attending physician or facility must provide the necessary medical documentation including, but not limited to: Member's diagnosis, and/or Service(s) to be provided, and/or Special physical or medical limitations and/or requirements VI. Transportation Destinations: Member's meeting transportation criteria are covered for medically necessary services to the following destinations: 4

1. Hospital 2. Critical Access Hospital (CAH) 3. Skilled Nursing Facility 4. Patient s home 5. Dialysis facility for ESRD patient who requires dialysis; 6. Physician s office only as follows: The ambulance transport is en route to a covered destination; and During the transport, the ambulance stops at a physician's office because of the patient's dire need for professional attention, and immediately thereafter, the ambulance continues to the covered destination. VII. Out of Country Transportation: When a member has traveled outside of the United States, Mexico, Canada and the U.S. Territories, emergency or 911 transportation to the nearest hospital and/or hospital emergency facility does not require notification, pre-certification or certification. However, Oxford Medical Management should be notified of an admission within 48 hours or as soon as possible, consistent with the Member's certificate. All requests for other out of the country transportation, including repatriation, require precertification and Medical Director review. Refer to Members Outside of the United States for additional information on coverage for services received outside of the United States, Mexico, Canada and the U.S. Territories. VIII. Air Transportation Medically necessary air transportation is covered regardless of State or region and when: 1. The Member's medical condition is such that transportation by either basic or advanced life support land transport is not appropriate; and 2. The Member's medical condition requires immediate and rapid transportation that cannot be provided by land and one of the following is met: a) The point of pick-up is inaccessible by land vehicle; or b) Great distances or other obstacles (for example, heavy traffic) prevent the patient's timely transfer to the nearest hospital with appropriate facilities. The following is a list of examples for which air transport could be justified. The list is not inclusive of all situations that justify air transportation, nor is it intended to justify air transportation in all locales in the circumstances listed. Intracranial bleeding - requiring neurosurgical intervention Cardiogenic shock Burns requiring treatment in a burn center Conditions requiring treatment in a Hyperbaric Oxygen Unit Multiple severe injuries Life threatening trauma IX. Paramedic Intercept Services The term "intercept service" is used to describe a service (frequently ALS) provided by a paramedic team working under a contractual arrangement with a local volunteer ambulance company that is capable of providing only BLS service. 5

DEFINITIONS Coverage will be provided for paramedic intercept when it is provided in a rural area and all of the following conditions are met: 1. Services are: provided under contract with one or more volunteer ambulance/transportation services; and medically necessary, based on the condition of the patient receiving the transportation service; and 2. The volunteer ambulance/transportation service involved: is certified as qualified to provide ambulance/transportation services for purposes of this provision; and was capable of providing only BLS services at the time of the intercept; and is prohibited by state law from billing for any service; and 3. If the ALS paramedic intercept service: is certified as qualified to provide the services; and bills all recipients who receive ALS paramedic intercept services Ambulance: A vehicle staffed and equipped to respond to a medical emergency or acute care situation. Air Ambulance: Transportation provided by either fixed wing or rotary wing aircraft. Fixed Wing Aircraft: air transportation provided by an airplane Rotary Wing Aircraft: air transportation provided by a helicopter Ambulette: A non-emergency vehicle that accommodates wheelchairs and/or stretchers and provides assisted transport, but does not provide skilled medical services en route. Repatriation: Returning a person to their place of origin or citizenship. Rural Area: Services in a rural area are services that are furnished (1) in an area outside a Metropolitan Statistical Area (MSA); or, (2) in New England, outside a New England County Metropolitan Area (NECMA); or, (3) an area identified as rural using the Goldsmith modification even though the area is within an MSA. APPLICABLE CODES The codes listed in this policy are for reference purposes only. Listing of a service or device code in this policy does not imply that the service described by this code is a covered or non-covered health service. Coverage is determined by the Member s plan of benefits or Certificate of Coverage. This list of codes may not be all inclusive. Applicable HCPCS Codes HCPCS Code A0225 A0380 A0390 A0422 Description Ambulance service, neonatal transport BLS mileage (per mile) ALS mileage (per mile) Ambulance (ALS or BLS) oxygen & oxygen supplies, life sustaining situation 6

HCPCS Code Description A0424 Extra ambulance attendant, ground (ALS or BLS) or air (fixed or rotary winged); (requires medical review) A0425 Ground mileage, per statute mile A0426 Ambulance service, advanced life support, non-emergency transportation A0427 Ambulance service, advanced life support, emergency transport, level 1 (ALS 1 - emergency) A0428 Ambulance service, basic life support, non-emergency transportation A0429 Ambulance service, basic life support, emergency transport (BLS - emergency) A0430 Air ambulance service, one way, fixed wing A0431 Air ambulance service, one way, rotary wing A0432 Paramedic Intercept (PI) rural area, transportation furnished by volunteer ambulance company which is prohibited by law from billing 3rd party payers A0433 Advanced life support, level 2 (ALS 2) A0434 Specialty care transport (SCT) A0435 Fixed wing air mileage, per statute mile A0436 Rotary wing air mileage, per statute mile A0998 Ambulance response and treatment, no transport Non-Covered HCPCS Codes HCPCS Code A0080 A0090 A0100 A0110 A0120 A0130 A0140 A0160 A0170 A0180 A0190 A0200 A0210 A0888 Description Non-emergency transportation, per mile - vehicle provided by volunteer (individual or organization) with no vested interest Non-emergency transportation, per mile - vehicle provided by volunteer (individual or organization) with vested interest Non-emergency transportation: taxi Non-emergency transportation: bus, intra or interstate carrier Non-emergency transportation: mini-bus, mountain area transports or other transportation systems Non-emergency transportation: wheelchair van Non-emergency transportation and air travel (private or commercial) intra- or interstate Non-emergency transportation: per mile, caseworker or social worker Transportation ancillary: parking fees, tolls, other Non-emergency transportation: ancillary: lodging - recipient Non-emergency transportation: ancillary: meals - recipient Non-emergency transportation: ancillary: lodging - escort Non-emergency transportation: ancillary: meals - escort Noncovered ambulance mileage, per mile (e.g., for miles traveled beyond closest appropriate facility) DESCRIPTION OF SERVICES Transportation services may include ambulance (land, water or air) when a Member is in need of medically necessary services. Coverage will be provided for transportation service(s) appropriate for the Member's medical need. REFERENCES 1. CT Public Act 02-124 - An act concerning health insurance coverage for ambulance services codified at C.G.S.A. 38a-498; 38a-525 (West 2003). 2. Final rule, (Medicare News Brief). Medicare News Brief- New Jersey, Part B. 3. Medicare Benefit Policy Manual, Chapter 10 Ambulance Services, last accessed March 2012: http://www.cms.gov/manuals/downloads/bp102c10.pdf 4. SB 5213: Coverage for pre-hospital emergency medical care provided by an ambulance services codified at N.Y. Insurance Law 3216(24); 3221 (15) (McKinney 2003). 7

POLICY HISTORY/REVISION INFORMATION Date 03/01/2015 Action/Description Changed policy type classification from Clinical to Administrative (no change in content/guidelines) Archived previous policy version TRANSPORT 002.14 T2 8