Policy Title: Ambulance Service Effective Date: 10/25/01 Clinical Policy Guideline Date Reviewed: 01/18/11, 03/19/14, 05/21/14, 07/29/2015 I. DEFINITION Ambulance service means a ground, sea or air vehicle specially designed and equipped to primarily provide transportation for the ill and injured. It provides specialized equipment to treat patients before and during transportation to an appropriate medical facility, and has a crew of at least two persons, in which at least one individual has adequate first aid training for patient care. Emergency is a sudden onset of a medical condition exhibiting itself by acute symptoms of such severity that the absence of immediate medical attention could reasonably be expected to result in any of the following: Placing the patient s health in serious jeopardy; Serious impairment to bodily functions: or Serious dysfunction of any bodily organ or part. Non-emergency refers to all scheduled transportation regardless of origin and destination that does not meet the above criteria for an emergency. Examples of scheduled transportation include, but are not limited to, the following: Hospital discharge trips, Trips to and from end stage renal dialysis (ESRD) facilities for dialysis, To and from other outpatient facilities for chemotherapy or radiation therapy and other diagnostic and therapeutic services. Medical Necessity is established when the patient s clinical condition, at the time the service is provided, is such that the use of any other method of transportation could result in endangering the patient s health, or when another method of transportation is contraindicated, e.g., automobile, taxi, wheelchair van or bus. Coverage is also provided if the patient was bed confined before and after the ambulance trip. Page 1 of 7
Bed Confined is defined as the patient s inability to get up from bed without help, and unable to ambulate, and unable to sit in a chair or wheelchair. All three conditions must be met in order to meet the bed confinement definition. II. POLICY/CRITERIA Ambulance service coverage is usually limited to transportation for a covered service from wherever the need may arise to a hospital or skilled nursing facility, or between hospitals or skilled nursing facilities, or from a hospital or a skilled nursing facility to a member s home when it is medically necessary for the member at the time of the service. Documentation supporting medical necessity must be documented, legible and upon request, available for review. A. General requirements for air and ground ambulance are as follows: 1. The vehicle is specially designed and equipped as indicated in the above definition, 2. The vehicle must comply with state or local laws governing the licensing, certification, and equipment requirements of an emergency medical transportation vehicle, 3. The crew (> 2) has specialized training in first aid to provide the necessary medical care services, 4. The trip is medically necessary for the member s condition, and 5. The member satisfies the requirement of bed confined. B. Emergency ground ambulance transport services are covered when the following criteria are met: 1. The member s condition at the time of the ambulance trip satisfies the definition of medical necessity and qualifies as an emergency situation, and 2. The mode of transportation is appropriate to the member s actual medical condition at the time of service, and 3. Subsequent documentation supports the medical necessity, 4. Emergency ground ambulance transport services are covered for local transportation to the closest hospital that can provide medically necessary treatment to the member. C. Emergency Air Ambulance Transportation, (helicopter or fixed wing aircraft) and/or Sea is covered when all of the following criteria are met: 1. When it would take a land ambulance 30-60 minutes or more to transport an emergency patient, and/or 2. The member s medical condition requires immediate and rapid transport that cannot be provided by either basic or advanced life support land ambulance, and 3. Either the point of pickup is not accessible by land vehicle, or great distances or other obstacles are involved in transporting the member to the nearest appropriate facility, and Page 2 of 7
4. The member is being transferred only to the closest acute care hospital that can provide the medically necessary treatment the member requires. D. Non-emergency ambulance transport services must meet the following criteria: 1. Non-emergent transport from inpatient hospital to inpatient hospital for medically necessary care does not require prior authorization. 2. For all other non-emergency ambulance transport services, the following criteria must be met: a) Prior authorization by HealthPlus is required, b) The patient s member s condition met the definition of bed confinement before and after the ambulance trip, and c) The member s condition establishes medical necessity for the ambulance service. F. Exclusions: 1. Non-emergent ambulance transportation (ground, air, and/or sea) of medically stable members for the convenience of the member, member s family, and/or the member s physician is not covered. 2. This exclusion explicitly includes transportation to any medical facility other than the hospital that a HealthPlus Medical Director determines is the most appropriate to provide the medically necessary treatment the member requires. 3. Round trips from a hospital inpatient setting to a medical specialist facility for the convenience of the physician or for the use of medical equipment either available at the institution or that can be transported to the institution. 4. Round trips when a member is taken from a hospital to another facility and returned to the same hospital. As long as the member is an inpatient, all ancillary services are the responsibilities of the hospital. F. Out-of Area and Foreign Ambulance service: 1. Medically appropriate ambulance transportation is a covered benefit regardless of where the service is obtained. 2. Non-emergent interstate air, sea or ground transportation requires a prior authorization by HealthPlus, and is subject to the requirements and exclusions in Section E, above. G. Emergency Health Care Services without Ambulance Transport: In certain circumstances a member may receive health care services from ambulance personnel without subsequent ambulance transportation. Usually, the cost for these services is absorbed by a local governmental agency, since they are considered to offer a community health benefit. However, in rare circumstances members have been billed for these services. When a member has been billed for this Page 3 of 7
service, HealthPlus will provide coverage in very limited circumstances, when all the following criteria apply: 1. In the judgment of a prudent observer, an emergency situation did exist when the ambulance services were requested, 2. The ambulance services were not used as a substitute to avoid transportation to, and/or receiving care from, a health care practitioner or facility, 3. Transportation was declined because the precipitating health incident had readily resolved, and did not require further medical intervention or assessment. III. PRIOR AUTHORIZATION REQUIREMENTS Prior authorization by the Medical Director as required in the above criteria. Refer to the Prior Authorization Chart below for Requirements G:\Clinical Policy Committee\BIC R&C FOLDER\Ambulance Service Prior Authorization Requirements.xls IV. CODING/MODIFIERS/LOCATION OF SERVICE Applicable HCPCS Codes: A0225 Ambulance service, neonatal transport, base rate, emergency transport, one way A0420 Ambulance waiting time (ALS or BLS) one-half (1/2 hour) increments. A0425 Ground mileage, per statue mile A0426 Ambulance service, advanced life support, non-emergency, level 1 (ALS 1) A0427 Ambulance service, advanced life support, emergency transport, level 1 (ALS 1 emergency) A0428 Ambulance service, basic life support, non-emergency transport (BLS) A0429 Ambulance service, basic life support, emergency, (BLS emergency) A0430 Ambulance service, conventional air service, transport, and one way (fixed wing) A0431 Ambulance service, conventional air service, transport one way (rotary wing) A0432 Paramedic intercept (PI), rural area, transport furnished by a volunteer ambulance company which is prohibited by state law from billing third-party payers A0433 Advanced life support, level 2 (ALS 2) A0434 Specialty care transport (SCT) A0435 Fixed wing mileage, per statue mile A0436 Rotary wing air mileage, per statute mile A0998 Ambulance response and treatment, no transport A0999 Unlisted ambulance service Page 4 of 7
***THE ABOVE HCPCS CODES MAY NOT BE COVERED FOR ALL LINES OF BUSINESS*** Modifiers - Must include the appropriate origin and destination modifier on any service line billing for mileage. The first character of the modifier is the origin code and the second character of the modifier is the destination code (e.g. Use modifier RM for a transport from the residence to the emergency room). Origin and Destination Modifiers: D Diagnosis or therapeutic site other than P or H when these are used as origin codes E Residential, domiciliary, custodial facility (nursing home, not skilled nursing facility) G Hospital based dialysis facility (hospital or hospital-related) H Hospital I Site of transfer (e.g., airport or helicopter pad) between types of ambulance J Non-hospital-based dialysis facility N Skilled nursing Facility (SNF) P Physician s office (Includes HMO non-hospital facility, clinic, etc.) R Residence S Scene of accident or acute event X Intermediate stop at a physician s office enroute to the hospital (includes HMO non-hospital facility, clinic, etc.) Destination code only. Modifier X can only be used as a designation code in the second position of a modifier. Used by both ground and air transports: GA The provider or supplier has provided an Advance Beneficiary Notice (ABN) to the patient. GM When more than one patient is transported in an ambulance and document details of the transport. GY Use when billing for a statutorily excluded services. Example patient transport is for noncovered condition that does not meet the definition of any Medicare benefit. The provider is expecting a denial. GZ The provider or supplier expects a medical necessity denial; however, did not provide an Advance Beneficiary Notice (ABN) to the patient. QL Patient pronounced dead after ambulance called QM Ambulance service provided under arrangement by a provider of services QN Ambulance service furnished directly by a provider of services TQ Basic life support transport by a volunteer ambulance provider Location of Service: 41- Ambulance Land 42- Ambulance Air or Water Page 5 of 7
V. PRODUCT LINE COVERAGE Please reference contract benefit rider, benefit description, Master Plan Document, Evidence of Coverage (EoC) and Certificate of Coverage (CoC) for applicable limits and copayments, including other exceptions and/or exclusions for specific coverage. If there is a conflict between this medical policy and the individual or group insurance policy document, the terms of the individual or group insurance policy will govern, unless specifically noted. HMO: This policy applies to insured HMO plans; refer to the CoC or benefit rider for exceptions or exclusions. PPO: This policy applies to PPO plans; refer to the CoC for any exceptions or exclusions. SELF-FUNDED OPTIONS: This policy applies to self-funded option plans; refer to the Master Plan Document for any exceptions or exclusions. MEDICARE ADVANTAGE: This policy applies to insured Medicare Advantage plans; refer to the EoC for any exceptions or exclusions. MEDICAID: This policy applies to Medicaid plans; refer to the subscriber contract for exceptions or exclusions. HEALTHY MICHIGAN PLAN: This policy applies to Healthy Michigan Plan; refer to the subscriber contract for any exceptions or exclusions. MICHILD: This policy applies to insured MICHILD plans; refer to the subscriber contract for any exceptions or exclusions. COUNTY HEALTH PLANS: This policy applies to County Health Plans; refer to the benefit description for any exceptions or exclusions. VI. REFERENCES References are available upon request. AMA CPT Copyright Statement: All Current Procedure Terminology (CPT) codes, descriptions, and other data are copyrighted by the American Medical Association. This policy is for informational use only; therefore it is not an authorization of services. HealthPlus of Michigan s clinical policies are developed with the assistance of medical professionals and are based upon a review of published and unpublished information including, but not limited to, current medical literature, guidelines published by public health and health research agencies, and community medical practices in the treatment and diagnosis of disease. Because medical practice, information, and Page 6 of 7
technology are constantly changing, HealthPlus of Michigan reserves the right to review and update its clinical policies at its discretion. HealthPlus of Michigan s clinical policies are intended to serve as a resource to the plan; however they are not intended to limit the plan s interpretation of benefit language. HealthPlus of Michigan does not provide health care services and cannot guarantee results or outcomes. Treating providers are solely responsible for rendering medical advice and treatment to members. Page 7 of 7