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Ambulance Services: Ground Transportation

Section: Ancillary
Effective Date: July 01, 2018
Revised Date: January 13, 2020

Description

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.

Criteria

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):

  • Was transported in an emergency situation, e.g., as a result of an accident, injury or acute medical or psychiatric illness; or
  • Needed to be restrained; or
  • Was unconscious or in shock; or
  • Required oxygen (due to hypoxemia, syncope, airway obstruction or chest pain) or other emergency treatment on the way to the destination; or
  • Had to remain immobile because of a fracture that had not been set or the possibility of a fracture (e.g., hip fracture, compound fracture, severe pain with need for intravenous pain medication or neurological injury); or
  • Sustained an acute stroke or myocardial infarction; or
  • Was experiencing severe hemorrhage; or
  • Was bed confined before and after the ambulance trip (see note below); or
  • Could be moved only by stretcher because of a specific physical condition or limitation; or
  • Lower extremity contractures creating non-ambulatory status and the individual cannot sit in a wheelchair (severe fixed contractures proximal to the knee); or
  • Severe generalized weakness from a health condition that would be exacerbated by transport in a vehicle other than an ambulance; or
  • Severe vertigo causing inability to remain upright; or
  • Immobility of lower extremities (Spica or full body cast, fixed hip joints or lower extremity paralysis and unable to be moved by wheelchair).

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:

  • Unable to get up from bed without assistance; and
  • Unable to ambulate; and
  • Unable to sit in a chair or wheelchair.

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.

Destination Requirements

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)

Procedure Codes 

A0998

Ambulance Intercept
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.

Procedure Codes

A0225 A0380 A0390 A0425 A0426 A0427 A0428
A0429 A0433 A0434 A0888 A9270 S0215

Paramedic Intercept
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.

Procedure Codes

A0432 S0207 S0208

Ambulance Transportation Services

Miscellaneous

  • Ambulance providers are required to retain documentation on file supporting all ambulance services (i.e., trip sheets).
  • More than one individual may be transported, e.g., from the scene of a traffic accident.
  • When multiple individual transports are reported, the statement “multiple individuals” and the number transported must be documented.
  • Ambulance services that are provided for individual or family convenience is not a covered benefit.