Description
This complex review will be examining rotatory wing (helicopter) aircraft claims or fixed wing (airplane) claims to determine if air ambulance transport was reasonable and medically necessary as well as whether documentation requirements have been met.
Affected Code(s)
A0430, A0431, A0435, A0436
Applicable Policy References
1.. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(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. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1861(s)(7)- Medical and Other Health Services
4. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1834 (I)(14)- Establishment of Fee Schedule for Ambulance Services
5. 42 CFR §405.929- Post-Payment Review
6. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
7. 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
8. 42 CFR §405.986- Good Cause for Reopening
9. 42 CFR §410.40- Coverage of ambulance services, (c) Levels of service; (e) Medical necessity requirements
10. 42 CFR §410.41- Requirements for ambulance providers and suppliers, (c) Billing and reporting requirements.
11. 42 CFR §414.605 Definitions
12. 42 CFR §414.610 Basis of Payment
13. 42 CFR §424.36- Signature Requirements
14. 42 CFR §424.37- Evidence of Authority to Sign on behalf of the Beneficiary
15. 42 CFR §424.5- Basic Conditions, (a)(6) Sufficient Information
16. Medicare Benefit Policy Manual (MBPM), Chapter 10- Ambulance Services, §10.4 Air Ambulance Services, §20.1.2 Beneficiary Signature Requirements, §30.1.2 Air Ambulance Services Medicare Claims Processing Manual, Chapter 15- Ambulance, §20.3 Air Ambulance
17. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
18. HCPCS Level II Codebook