Ambulance Services

Policy ID: NDRP_Ambulance_001
Section: Ambulance Services
Effective Date: January 01, 2020
Last Reviewed: January 13, 2020

Description

This policy provides guidelines for correct billing and reimbursement for ambulance services.

Definitions

Ambulance Specially designed or equipped vehicle used only for transporting the critically ill or injured to a health care facility. The ambulance service must meet state and local requirements for providing transportation for the critically ill or injured and must be operated by qualified personnel who are trained in the application of basic life support.
Hospital-based Ambulance Ambulance owned/operated by a hospital for purposes of providing ambulance transport.
Independent Ambulance Ambulance company not owned/operated by a hospital which provides ambulance transport.
Loaded Miles Miles incurred after member is loaded onto ambulance for transport.
Point of Pickup Location of the member at the time member is placed on board the ambulance.

Reimbursement Policy

Reimbursement will be based on the Base Rate and Mileage HCPCS codes that define the type of service provided.

The base rate covers routine supplies and equipment such as IV solutions, oxygen, tubing, masks, gloves, dressings, catheters, EKG supplies, backboards, glucose checks and basic medications.

Other services or supplies billed in addition to the base rate will be denied as an integral part of the actual transportation. An example of these would include:

Supply codes A0382, A0384, A0392, A0394, A0396, A0398
Waiting Time A0420
Oxygen A0422
Extra Attendant A0424
Protective garments A4927, A4928, A4930
Cardiac monitoring (including EKG) 93000-93010, 93040-93042
Pulse Oximetry 94760 and 94761

When billing for mileage, report the number of loaded miles in the “units” field. For CMS-1500 Claim form billing, any mileage less than 100 miles, report the mileage as a numeric value that includes tenths of a mile; any mileage greater than or equal to 100 miles, report the mileage to the nearest whole number. For UB-04 Claim Form billing, submit to the nearest whole mile, regardless of number of miles.

Ambulance services provided by an independent ambulance provider must be billed on the CMS-1500 Claim Form.

Ambulance services provided by a hospital-based ambulance must be billed on the UB-04 Claim Form using the specific National Provider Identifier (NPI) assigned for ambulance. These services should not be billed under the acute hospital NPI. Hospital-based ambulance services are not allowed on inpatient claims, as ambulance transport is not included in inpatient reimbursement methods. Claims for ambulance services must be submitted separately as an outpatient claim. An exception for billing ambulance services through the acute hospital NPI is discussed below in the Intra-facility Ambulance Transport section.

Level of Service

If an Advanced Life Support (ALS) vehicle is used but no ALS service is performed, the appropriate Basic Life Support (BLS) codes should be used. For criteria on higher intensity services refer to the NDBCBS Ambulance Medical Policy.

Intra-facility Ambulance Transport

Medically necessary transports between provider sites will be reimbursed for the following conditions:

  • The two locations have different NPIs
  • The campuses are in two different locations (a campus is defined as areas located within 250 yards of main buildings) AND the member is not in an inpatient status at the time of transport.

Examples of transports eligible for payment:

    • A member who demonstrates severe behavioral health issues is seen in a provider’s emergency room (ER) and is transported by ambulance for admission to the same provider’s psychiatric unit located outside of the campus containing the ER or to the psychiatric unit that has a different NPI.
    • A member treated in the clinic for physical therapy services has a stroke and requires transport to a hospital ER for medical treatment.
    • A member having a surgical procedure done in the Ambulatory Surgery Center (ASC) has a severe hemorrhage and requires transport to the hospital for additional care.

Examples of transports not eligible for separate payment:

    • A member is hospitalized at Hospital A as an inpatient. The member requires diagnostic tests and is transported by ambulance to Hospital B for the test and then returns to Hospital A for continued inpatient care. Both the test plus the ambulance transport charges would be included on the inpatient claim submitted by Hospital A. Hospital A would be responsible for reimbursing the Ambulance Company and Hospital B services they provided.
    • A member has a procedure performed in a facility’s ASC and is transported to the same facility’s outpatient hospital for additional non-emergent care/routine post-operative recovery.
    • Transport by an ambulance to a clinic or mortuary is not eligible for reimbursement.

Ambulance Transport of Multiple Patients

When multiple patients are transported simultaneously either by ground or air, regardless of whether it is billed by UB-04 or a CMS-1500 Claim Form, the following rules apply:

  • Two Patients: For two patients in the same ambulance, Blue Cross Blue Shield North Dakota (BCBSND) will reimburse at 75 percent of the allowed amount for the level of service (base rate) furnished to each patient. The total mileage will be divided in two so each patient’s claim will be reimbursed for 50 percent of the allowed amount for the entire transport.
  • Three or more patients: For three or more patients in the same ambulance, BCBSND will reimburse at 60 percent of the allowed amount for the level of service (base rate) furnished to each patient. The total mileage will be divided by the number of patients transported. For example, if three patients are transported in the same ambulance, the provider will be reimbursed for 60 percent of the allowed amount for each level of service (base rate) and 33 percent of the allowed amount for the total mileage for each patient.
  • Submit separate claims for each patient with the modifier ‘GM’; appended to both base rate and mileage codes. Submit the separate claims to BCBSND at the same time for each patient in the ambulance.

Ground Ambulance Billing Guidelines

BCBSND may contract with ground ambulance providers, if the provider’s headquarters or fully functioning business operations are located within BCBSND’s service area. Claims from providers of emergency and non-emergency ground ambulance services provided within the United States, U.S. Virgin Islands and Puerto Rico are to be filed to the local Plan. Member ground ambulance pick-up locations outside the United States, U.S. Virgin Islands and Puerto Rico, regardless of where the provider’s headquarters is located, must file claims to the Blue Cross Blue Shield Global Core medical assistance vendor for processing through the Blue Cross Blue Shield Global Core Program.

Federal Employee Program (FEP) ambulance claims should be filed to the BCBS Plan for the state where the member was picked up. If the provider is not contracted with that BCBS Plan and is contracted with the BCBS Plan in the state to which the member was transported, the claim may be filed to state BCBS Plan where the member was transported. For example, if an FEP member is picked up in Minnesota and brought to North Dakota, the FEP claim should be filed to Minnesota. In the event the ambulance provider is not contracted with Minnesota and is contracted with North Dakota, then the FEP claim can be filed to North Dakota.

Air Ambulance Billing Guidelines

Providers must submit claims for emergency and non-emergency air ambulance services provided within the United States, U.S. Virgin Islands and Puerto Rico to the local Plan in the service area the point of pickup zip code is located. BlueCard rules for claims incurred in an overlapping service area and contiguous county apply. If the member’s pickup location is outside the United States, U.S. Virgin Islands and Puerto Rico, the Provider shall submit these claims to the Blue Cross Blue Shield Global Core medical assistance vendor for processing through the Blue Cross Blue Shield Global Core Program.

The point of pickup zip code is based on the following CMS guidelines for air ambulance claims:

  • Independent Ambulance – Submit on CMS-1500 Claim Form
    • Paper Box 23 – Enter Point of Pickup 5-digit zip code
    • 837 Electronic Professional Claim X12N Loop – Enter Point of Pickup 5-digit zip code
      • Note: If the zip code is not in the Plan’s service area, the claim will be rejected.
  • Hospital-Based Ambulance – Submit on UB-04 Claim Form (Excluding claims submitted with a facility’s negotiated arrangement with an air ambulance provider.)
    • Paper Form Locator 39 – 41 – Enter Value code A0 with Point of Pickup 5-digit zip code
    • 837 Electronic Institutional X12N Loop – Enter Value code A0 with Point of Pickup 5-digit zip code.
      • Note: Claims without a point of pickup zip code or with multiple zip codes, will be rejected.

Air ambulance claim filing rules apply, regardless of the provider’s contracting status with the Blue Cross Blue Shield plan where the claim is filed. When possible, providers should verify member eligibility and benefits by calling the phone number listed on the back of the member’s BCBSND ID card or by calling 1-800-676-BLUE. Providers should use in-network participating air ambulance providers to reduce the possibility of members incurring additional liability for uncovered benefits. In-network participating air ambulance providers can be found by searching the National Doctor & Hospital Finder. Members are financially liable for any air ambulance services that are not covered under their BCBSND benefit plan, including charges that result from the use of providers that do not participate with BCBSND. The provider is responsible for billing members for non-covered services. Requests for or offers to contract with out-of-state air ambulance providers are reviewed on a case-by-case basis. BCBSND may contract with an air ambulance provider, if the air ambulance’s patients will be picked up in a location that is within BCBSND’s service area based upon the zip code of the point of pickup.

State Legislation

According to ND State Law, hospitals must notify members in non-emergency situations which air ambulance providers have a contractual agreement with the member’s health insurance company. Effective January 1, 2018, all payments made by North Dakota insurers for air ambulance services shall be at the same in-network level and considered as payment in full, even for out-of-network air ambulance services. These regulations apply to only air ambulance providers licensed in the state of North Dakota and only to members of fully-insured groups.

Limitations and Exclusions

While reimbursement is considered, payment determination is subject to, but not limited to:

  • Group or Individual benefit
  • Provider Participation Agreement
  • Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
  • Mandated or legislative required criteria will always supersede.

In instances where the provider is participating, based on member benefits, co-payment, coinsurance, and/or deductible shall apply.

Cross Reference

Revisions

Date Revisions
01/13/2020 Edited the layout of the text.
01/07/2020 Added disclaimer and moved services that are included in base rate under the reimbursement policy section.
12/23/2019 Removed from provider manual and separated medical policy and reimbursement policy. Updated mileage requirements for claims submitted on the UB-04 claim form.

Disclaimer

Reimbursement policies are intended only to establish general guidelines for reimbursement under BCBSND plans. BCBSND retains the right to review and update its reimbursement policy guidelines at its sole discretion.