Reimbursement Plicy Subject: Transprtatin Services: Ambulance and Nn-Emergent Transprt Effective Date: 08/18/14 Cmmittee Apprval Obtained: 08/18/14 Sectin: Transprtatin ***** The mst current versin f ur reimbursement plicies can be fund n ur prvider website. If yu are using a printed versin f this plicy, please verify the infrmatin by ging t www.empireblue.cm/nymedicaiddc ***** These plicies serve as a guide t assist yu in accurate claim submissins and t utline the basis fr reimbursement by Empire BlueCrss BlueShield HealthPlus (Empire) if the service is cvered by a member s Empire 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, Empire may: Reject r deny the claim Recver and/r recup claim payment Empire 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 These plicies may be superseded by mandates in prvider, state, federal r CMS cntracts and/r requirements.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, Empire strives t minimize these variatins. Empire 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. www.empireblue.cm/nymedicaiddc Empire BlueCrss BlueShield HealthPlus is the trade name f HealthPlus, LLC, an independent licensee f the Blue Crss and Blue Shield Assciatin. WEB-NYE-0016-15 Octber 2015
Empire BlueCrss BlueShield HealthPlus Transprtatin Services Page 2 f 7 Empire 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, Empire recmmends that prviders als review state guidelines fr cverage requirements. Plicy 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. In sme instances, NEMT services are prvided thrugh a state vendr, nt Empire. 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 separately reimbursable frm the ambulance base rate If ambulance transprt is medically necessary fr inpatient-tinpatient transfer between hspital-based facilities, reimbursement is included in the inpatient stay If an ambulance transprt fr newbrn infant is transprted frm the birth hspital t a Reginal Perinatal Care Center, reimbursement f ambulance transprt is separate frm the inpatient stay
Empire BlueCrss BlueShield HealthPlus Transprtatin Services Page 3 f 7 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 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 P r H Mdifier E: Residential, dmiciliary, custdial facility Mdifier G: Hspital-based dialysis facility (hspital r hspitalassciated) Mdifier H: Hspital (inpatient r utpatient) Mdifier I: Site f transfer between types f ambulance Mdifier J: Nnhspital-based dialysis Mdifier N: Skilled Nursing Facility (SNF), including swingbed 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
Empire BlueCrss BlueShield HealthPlus Transprtatin Services Page 4 f 7 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 Empire 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: Fr reasns ther than medical care Where anther means f transprtatin culd be used withut endangering the member s health Fr separate reimbursement fr services/items included in the base ambulance rate
Empire BlueCrss BlueShield HealthPlus Transprtatin Services Page 5 f 7 Fr a higher level f care when a lwer level is mre 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 Initial Empire review apprved and effective 08/18/14 References and Research Materials Definitins This plicy has been develped thrugh cnsideratin f the fllwing: CMS State Medicaid State cntracts 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
Empire BlueCrss BlueShield HealthPlus Transprtatin Services Page 6 f 7 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 trained as Emergency Medical Technicians (EMTs) (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 (i.e. laypersns) t receive cvered services. There are several types f medical transprts: ambulette/medi-van, wheelchair van, invalid cach, taxicab, minibus, and public transprtatin (i.e. 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
Empire BlueCrss BlueShield HealthPlus Transprtatin Services Page 7 f 7 Related Plicies Prtable/Mbile/Handheld Radilgy Services Related Materials Nne