Ambulance Coverage Guidelines

Provider Participation Guidelines

To participate in the Medicaid Program, providers must be located and performing services in Rhode Island or in a border community  PDF. Consideration will be given to out-of-state providers if the covered service is not available in Rhode Island, the recipient is currently residing in another state or if the covered service was performed as an emergency service while the recipient was traveling through another state.
Ambulance providers must attach a copy of each of their vehicles’ licenses with their application when enrolling in the Medicaid Program.

Recertification

Ambulance providers are annually recertified by the Rhode Island Department of Health (DOH). The license expiration date for ambulance providers is December 31. Providers obtain license renewal through DOH and then forward a copy of the renewal documentation to DXC Technology. DXC Technology should receive this information as soon as possible to avoid suspension from the program.

Providers in border communities must send in copies of their recertification to ensure continuation in the program.

A provider may appeal to the DOH if they do not meet the recertification criteria. If the appeal to DOH is not successful, the provider may then appeal to the Centers for Medicare and Medicaid (CMS). Instructions for completing the CMS1500 claim form are in Claims Processing.

Claims Billing Guidelines

Instructions for completing the CMS 1500 claim form are in Claims Processing.

Origin/Destination Modifiers

The claim must include a two-letter origin-destination modifier indicating were a trip begins and ends.

Town codes indicating the origin and destination of a trip must be included on the claim form.

Covered and Non-Covered Services

The Medicaid Program Covers emergency and non-emergency emergency transportation of patients who cannot sit, stand or walk. Only ground transportation is covered. Wheelchair or air transportation is not a covered service. The type of trip (emergency/non-emergency) must be consistent with the diagnosis of the patient transported (e.g., a trip billed as emergency transport would not be covered if the patient had a non-emergency diagnosis).

Ambulatory Transportation

Ambulatory transportation will be reimbursed when the recipient has no other means of free transportation, no community resource exists and transportation by any other means would endanger the individual’s health and must include a two-letter origin-destination modifier indicating were a trip begins and ends.

SNF or ICF Resident

An individual residing in a Skilled Nursing Facility (SNF) or Intermediate Care Facility (ICF) whose condition precludes transportation by the facility automobile to and from physician’s office, medical laboratory, hospitals, etc., may be transported by ambulance subject to the following restrictions.

Ambulance services should only be utilized when the patient cannot be transported by any other means and when the required medical service cannot be provided within the facility.
Ambulance services should not be utilized to transport patients to receive services that can be provided within the facility; e.g., portable x-ray services can be provided in a facility setting.

Ambulance services should only be provided when a patient is severely ill or injured and transportation by any other means would endanger the individual’s health. If a patient can be transported by a vehicle other than an ambulance, it is the responsibility of the facility to ensure that the patient is transported by alternative means whenever possible.

Out of State

Out-of-state ambulance trips can be considered for payment on the basis of medical necessity. Medical necessity is determined by the patient’s signs and symptoms at point of pick-up. Such services will require prior authorization. EOHHS may give oral prior authorization. However, this must be followed up by submitting a written request for authorization. Refer to prior authorization for guidelines and procedures.

Round Trips

Emergency transportation will not be reimbursed for transport back to the point of origin. Emergency round trips are reimbursed only if the patient is transported out of state and back. Non-emergency round trips can be reimbursed if the recipient cannot sit, stand or walk.

Repeat Trips/Extra Attendants

Repeat trips for a patient on the same day will be denied as a duplicate service. Extra attendants or physician/hospital staff accompanying a patient enroute are not a covered benefit.

Prior Authorization

 When requesting authorization, medical justification must be documented.

Physician's Statement

Non-emergency transport by ambulance requires a written statement by the recommending physician. This statement must include the recipient’s medical condition and why ambulance transportation is required. This statement must be kept on file by the Ambulance provider and must be readily available to EOHHS for utilization review. If the non-emergency transportation is on-going (such as for kidney dialysis), one statement can be used for a period of one year.

Retroactive Authorization

Procedures normally requiring prior authorization that were performed on an emergency basis may receive retroactive authorization if the procedure was medically necessary and meets all the other requirements that would have been required for normal authorization. Procedures billed retrospectively for recipients who have retroactive eligibility are valid if all other conditions for billing are met.

Reimbursable Ambulance Procedure Codes

The following table lists all ambulance services reimbursable through the Medicaid Program. The table shows the procedure code, service description and if the service requires prior authorization (Y-yes or N-no). Immediately following the table are descriptions of the services covered under each procedure and any service limitations.

Procedure Code O-Obsolete Date
E- Effective Date
Description Prior Authorization
A0010 O-12/1/95 Basic Life Support (BLS) Base Rate,emergency transport, one way No
A0302 E-1/1/95 Ambulance service, BLS, emergency transport, all inclusive (mileage and supplies) No
A0322 E-1/1/95 Ambulance service, BLS, emergency transport, supplies included, mileage separately billed No
  A0342 E-1/1/95 Ambulance service, BLS, emergency transport, mileage included, disposable supplies separately billed No
A0020 O - 12/1/95 BLS per mile, transport, one way No
A0380 E - 1/1/95 BLS per mile, transport, one way, units 1-50 No
A0021 E - 4/1/93 Outside state per mile, transport (Medicaid only) Yes
A0060 O - 12/1/95 Waiting time, one half hour increments (out-of-state only) Yes
A0420 E - 1/1/95 Waiting time (ALS or BLS), 1/2 hour increments (out-of-state only) Yes

ALS andBLS

ALS includes oxygen and heart monitoring devices and is indicated if a condition is life-threatening. BLS does not include oxygen. The level of support is determined by the services that are provided enroute. Additional life support services are not separately payable.

Mileage

The first ten miles are included in the base rate for BLS/ALS. Each additional mile, up to 50 miles, will be reimbursed. There is no additional reimbursement for more than 50 miles.

Out of State Mileage

The first ten miles are included in the base rate. Each additional mile will be reimbursed up to 250 miles. There is no additional reimbursement for more than 250 miles.

Waiting Time

Waiting time is reimbursed for out-of-state trips up to a maximum of two hours. In-state waiting time is included in the base rate.

Oxygen

The need for oxygen must bear a reasonable relationship to the medical diagnosis and requirements of the patient. Oxygen will not be allowed on a routine basis.

Multiple Patients

More than one recipient may be transported by the same ambulance on the same trip. The second recipient will be reimbursed at a minimum rate for the first ten miles, or a maximum if the trip exceeds 10 miles.

Reimbursement Guidelines

The reimbursement rates for Ambulance providers are listed on the Fee Schedule. Providers must bill the Medicaid Program for their usual and customary rate (UCR) as charged to the general public and not for the published fee schedule amount. Rates discounted to specific groups (such as Senior Citizens) must be billed at the same discounted rate to the Medicaid Program. Payments to providers will not exceed the maximum reimbursement rate of the Medicaid Program.

Medicare/Medicaid Crossover

The Medicaid Program reimbursement for crossover claims is always capped by the established Medicaid allowed amount, regardless of coinsurance or deductible amounts. The standard calculation for crossover payments is as follows:

Medicaid will pay the lesser of:

The difference between the Medicaid allowed amount and the Medicare Payment (Medicaid allowed minus Medicare paid); or

The Medicare coinsurance and deductible up to the Medicaid allowed amount, calculated as follows: (Medicare coinsurance/deductible + Medicare paid) - (Medicaid allowed).

Patient Liability

The Medicaid Program reimbursement is considered payment in full. The provider is not permitted to seek further payment from the recipient in excess of the Medicaid Program rate.

 

 

 

 

 

PDF All PDFs require the free Adobe Reader.

 

RI.giv

74 West Road | Cranston, RI 02920 | Contact Us | Directions
© RI.gov, Executive Office of Health & Human Services.
Sitemap | Privacy Policy

W3C