Ground ambulance transportation is defined as a specially designed or equipped vehicle used only for transporting the critically ill or injured to a health care facility.
To be covered, ambulance transportation must be medically necessary. Medical necessity is established when the individual’s clinical condition is such that the use of any other method of transportation, such as taxi, private car, or other type of vehicle would be contraindicated (i.e., would endanger the individual”s medical condition).
The individual’s condition at the time of the transport is the determining factor in whether a trip will be covered. The fact that the individual is elderly, has a positive medical history, or cannot care for himself/herself does not establish medical necessity.
Additionally, stair safety concerns or the individual’s inability to negotiate stairs, in the absence of another medical condition that meets medical necessity criteria, does not satisfy medical necessity criteria.
Benefits are not available for ambulance services when an ambulance was used simply for convenience or because other means of transportation was not available, e.g. wheelchair van transport (A0130) and stretcher van transport (T2005, T2049).
Coverage may be available for expenses incurred by an individual for ambulance services that meet the following conditions (this is not an all-inclusive list):
NOTE: Post-hip replacement individuals may sit in a chair slightly higher than the average seat. This condition alone does not satisfy the medical necessity requirement. Post-knee replacement individuals should be able to bend their knee approximately 90 degrees at the time of discharge. This condition alone does not satisfy the medical necessity requirement.
NOTE: “Bed confinement” is defined as (all three conditions must be met):
The individual is:
Non-emergency ambulance transportation is not covered for individuals who are restricted to bed rest by a physician’s instructions but who do not meet the above three criteria. If some means of transportation other than an ambulance (i.e., private car, wheelchair van, etc.) could be utilized without endangering the individual’s health, regardless if such other transportation is actually available, no payment may be made for ambulance service.
Vehicle and Crew Requirement
The ambulance service must meet state and local requirements for providing transportation for the sick or injured and must be operated by qualified personnel who are trained in the application of basic life support.
Benefits will only cover ground ambulance services to the nearest appropriate medical facility, with the exception of well documented extraordinary circumstances (e.g. blizzard conditions). No benefits are allowed when a member/family requests to be transported to a facility farther away and the member is responsible for the additional mileage.
Treatment, No Transport
Benefits will be provided when an ambulance responds and BLS or ALS treatment is provided, but no transport of the individual takes place (e.g. individual refuses).
Benefits are not available if no treatment is provided (e.g. individual pronounced dead before ambulance arrives)
An ambulance intercept occurs when two ground ambulances are involved with the transport of a individual. Benefits will only be available to the ambulance company that delivers the individual to the hospital. That ambulance provider should bill for all services, including mileage for all loaded miles.
A paramedic intercept is defined as a paramedic that provides ALS services independent from the ambulance that transports the individual. When the transporting ambulance is classified as only being able to provide BLS services, but the transport meets an ALS level of service due to the paramedic intercept, the transporting ambulance should bill the ALS base rate. Benefits are available for the lesser of charges or the ALS fee schedule rate. A separate charge for the paramedic intercept is not reimbursable.
Ambulance Transportation Services