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Issue Number - Name
0154-Non-Emergency Ambulance Services-ALS and BLS: Medical Necessity and Documentation
Review Type
Complex
Provider Type
Ambulance
RAC Region/MAC Jurisdiction
R1-4
All
Date Approved
04/02/2019

Description

Medicare pays for nonemergency ambulance services when a beneficiary's medical condition at the time of transport is such that other means of transportation are contraindicated (i.e. would endanger the beneficiary). The beneficiary's condition must require the ambulance transportation itself and the level of service provided in order for the billed service to be considered medically necessary. The level of service is determined based on the patient's condition, not the vehicle used. Medical documentation for ambulance services will be reviewed to determine the Medicare defined conditions have been met for payment.

Affected Codes

A0426, A0428

Applicable Policy References

1. Social Security Act (SSA) § 1833 (e) Payment of Benefits.
2. SSA 1862(a)(1) states that no payment may be made under part A or part B for any expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.
3. SSA 1861(s)(7) defines ambulance service where the use of other methods of transportation is contraindicated by the individual’s condition, but only to the extent provided in the regulations.
4. SSA 1834(l) (10)-(16) Fee Schedule for Ambulance Services.
5. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
6. 42 CFR §405.986 Good Cause for Reopening
7. 42 CFR §424.5 (a)(6) Basic Conditions; Sufficient Information
8. 42 CFR 410.40 (b) Coverage of ambulance services; Levels of service.
9. 42 CFR 410.40 (d)(1) Coverage of ambulance services; Medical necessity requirements.
10. 42 CFR 410.40 (d)(2) Special rule for nonemergency, scheduled, repetitive ambulance services.
11. 42 CFR 410.40 (d)(3) Special rule for nonemergency ambulance services that are either unscheduled or that are scheduled on a non-repetitive basis
12. 42 CFR 410.41 (c) Requirements for ambulance suppliers; Billing and reporting requirements.

13. 42 CFR 414.605 Definitions
14. 42 CFR 414.610 Basis of Payment
15. 42 CFR 411.15 (k)(1) Particular Services Excluded from Coverage, Any Services not Reasonable and Necessary.
16. 42 CFR 424.36 Signature Requirements and 424.37 Evidence of Authority to Sign In on behalf of the Beneficiary.
17. IOM, 100-02, Medicare Benefit Policy Manual (MBPM), Chapter 10, §10 Ambulance Service; §20 Coverage Guidelines for Ambulance Service Claims; §30.1.1 Ground Ambulance Services, Emergency Response, Definition.
18. IOM, 100-04, Medicare Claims Processing Manual, Chapter 15, §30 (A) & (B), Modifiers Specific to Ambulance Service Claims and HCPCS Codes.
19. Novitas LCD L35162, Ambulance Services (Ground Ambulance). Effective Date 10/01/2015.
20. First Coast Service Options (FCSO), LCA A52588, Billing for Ground Ambulance Services when the Beneficiary is Pronounced Deceased. Effective Date 10/01/2015.
21. FCSO, LCD L33383, Non-Emergency Ground Ambulance Services. Effective Date 10/1/2015. Retirement Date 6/28/2018.
22. FCSO, LCD L37697, Emergency and Non-Emergency Ground Ambulance Services. Effective Date 6/28/2018.
23. Palmetto LCD L34549, Ambulance Services. Effective Date 10/01/2015.