Policy Statement
Our health plan adheres to following the guidelines on reimbursement of Ground Ambulance and Air Ambulance services:
Reimbursement is not allowed when the ambulance line-item service date falls within the admission and discharge dates on a hospital inpatient claim with the following exceptions:
- Reimbursement will be allowed when the ambulance line-item service date is the same as the admission or discharge date.
- Reimbursement is allowed for transportation, including transportation by ambulance, to and from another hospital or freestanding facility to receive specialized diagnostic or therapeutic services not available at the facility where the patient is inpatient. If the ambulance is owned by the hospital, then it should not be billed separately.
- When the beneficiary is an inpatient of a long-term care facility (LTCH), inpatient psychiatric facility (IPF) or inpatient rehabilitation facility (IRF) and is transported via ambulance to an acute care hospital to receive specialized services, reimbursement will be allowed if the presence of occurrence span code 74 (non-covered level of care) and the associated occurrence span code from and through dates is plus one day. The claim will be denied if the ambulance line item service date falls outside the occurrence span code 74 from and through dates plus one day.
- Reimbursement is allowed for SCT, however the reimbursement for SCT includes the provision of medically necessary supplies and services at a level of service beyond the scope of an EMT-Paramedic, these items/services will not be reimbursed separately.
Host Local Air Ambulance
Effective for date of service 04/19/2015 and after, air ambulance claims must be submitted to the Plan based on the point of pick-up (zip code). Claims that are either missing the pick-up zip code, or if the pick-up zip code is not in our service area, will be denied back to the provider.
Services Included in Ambulance Transportation
Per CMS services including, but not limited to oxygen, drugs, extra attendants, supplies, EKG, and night differential are not paid separately when reported as part of an ambulance transportation service.
Ambulance Modifiers
Reimbursement will only be made when billed with the two-digit ambulance modifier*. Any claim billed without the two-digit ambulance modifier will be denied.
*Exception: A0998 - Ambulance response and treatment, no transport - Ambulance service modifiers are not required. The submission of an ambulance modifier with this code may result in a denial. (A0998 is reimbursable for Commercial and Medicare Advantage)
Each ambulance modifier consists of two digits as follows:
- A single digit alpha character identifying the origin of the transport in the first position; and
- A single digit alpha character identifying the destination of the transport in the second position. (e.g., SH = scene of accident or acute event to hospital)
Below is a list of the modifiers eligible for reimbursement. Any claim billed without the two-digit ambulance modifier or modifier QL will be denied.
