0049 - Ambulance Transfer between Skilled Nursing Facilities: Unbundling

Description

Under the prospective payment system, some ambulance transportation provided by outside suppliers to SNF residents is included in the SNFs’ Medicare Part A payments and is subject to consolidated billing. Therefore, Medicare Part B payments that suppliers receive for the ambulance transportation are overpayments.

Affected Code(s)

A0021, A0080, A0090, A0100, A0110, A0120, A0130, A0160, A0170, A0180, A0190, A0200, A0210, A0225, A0380, A0382, A0384, A0390, A0392, A0394, A0396, A0398, A0420, A0422, A0425, A0426, A0427, A0428, A0429, A0432, A0433, A0434, A0998

Applicable Policy References

1.    Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
2.    Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
3.    42 CFR §405.929- Post-Payment Review
4.    42 CFR §405.930- Failure to Respond to Additional Documentation Request
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 §411.15(p)(3)(iv)- Services furnished to SNF residents
8.    Medicare Benefit Policy Manual, Chapter 10- Ambulance Services, §10.3.3- Separately Payable Ambulance Transport Under Part B Versus Patient Transportation That is Covered Under a Packaged Institutional Service
9.    Medicare Claims Processing Manual; Chapter 6- SNF Inpatient Part A Billing and SNF Consolidated Billing, §20.3.1- Ambulance Services
10.    Medicare Claims Processing Manual, Chapter 15- Ambulance, § 30.2.2- SNF Billing
11.    Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
12.    American Medical Association (AMA), Professional HCPCS Level II Manual 2014 to current