Coverage - JE Part B
Ambulance Coverage Requirements
Access the below ambulance coverage related information from this page.
- Advance Beneficiary Notice of Noncoverage (ABN) Tips for Ambulance
- Aborted Flight
- Bed-Confinement
- Both Origin and Destination are Ambulance Providers
- Coverage Requirements for Air
- Coverage Requirements for Ground
- Documentation Requirements
- Resources
- Transport Destinations
- Transports: Levels of Service
For ambulance services to be covered, they must follow the basic requirements below.
Air Ambulance
Coverage Requirements | Coverage Details |
---|---|
Service Meets Medical Necessity | Beneficiary's medical condition required immediate and rapid ambulance transportation that could not have been provided by ground ambulance; and either
Scheduled / Repetitive Medically Necessary Nonemergency - Medicare will cover medically necessary nonemergency, scheduled, repetitive ambulance services if the ambulance provider/supplier, before furnishing the service to the beneficiary, obtains a written order from the beneficiary's attending physician certifying that the medical necessity requirements of paragraph (d)(1) of this section are met. The physician's order must be dated no earlier than 60 days before the date the service is furnished. See Ambulance ABN related details. |
Beneficiary Transport Occurred | A transport must occur (not part of a Part A service) |
Local Destination | Transport destination must be local, which means that only mileage to nearest appropriate facility equipped to treat beneficiary will be covered. If two or more facilities meet requirement and can treat beneficiary, full mileage to any of these facilities will be covered |
Appropriate Facility | Not covered for transport to a facility that is not an acute care hospital. An appropriate hospital must have a physician or a physician specialist available to provide care required to treat beneficiary's condition |
Ground Ambulance
Coverage Requirements | Coverage Details |
---|---|
Service Meets Medical Necessity | Due to beneficiary's condition, use of any other method of transportation is not advised Transport is provided to obtain a Medicare-covered service or to return from obtaining such service No reimbursement will be made if a different means of transportation, other than an ambulance, could be used without endangering the individual's health, whether or not such other transportation is actually available. Ambulance benefit is defined in title XVIII of the Social Security Act (the Act) in §1861(s)(7): Ambulance service where the use of other methods of transportation is contraindicated by the individual's condition but only to the extent provided in regulations. Scheduled / Repetitive Medically Necessary Nonemergency - Medicare will cover medically necessary nonemergency, scheduled, repetitive ambulance services if the ambulance provider/supplier, before furnishing the service to the beneficiary, obtains a Physician Certification Statement (PCS) from his/her attending physician
See Ambulance ABN related details. |
Beneficiary Transport Occurred | A transport must occur (not part of a Part A service) |
Local Destination | Transport destination must be local, which means that only mileage to nearest appropriate facility equipped to treat beneficiary will be covered. If two or more facilities meet requirement and can treat beneficiary, full mileage to any of these facilities will be covered |
Appropriate Facility | An institution that is equipped to provide necessary hospital or skilled nursing care for beneficiary's illness or injury. An appropriate hospital must have a physician or a physician specialist available to provide care required to treat beneficiary's condition |
Transport to Home | In most cases, Medicare does not cover ambulance trips when ordered by facilities or providers to return the beneficiary to their home (Skilled Nursing Facility (SNF), assisted living, residence, etc.). An ambulance transport must meet the medical necessity "if other means of transportation would endanger the beneficiary's health, whether or not it's available." The transport becomes the beneficiary's financial burden. Many times, the SNF is responsible, under Consolidated Billing, for the transport. Other modes of transportation are to be used including a wheelchair van, cabulance, stretcher van, litter van, taxi, gurney van, transportation by a friend, neighbor or family member, ambulette, etc. Physicians, SNF employees, registered nurses (RNs), dialysis centers, discharge planners, social services, hospitals who order non-emergency ambulance transports should be aware of transports covered by Medicare and transports when other means of transportation is warranted. |
Resources
- Coverage
- CMS Internet Only Manual (IOM), Publication 100-01, Medicare General Information, Eligibility and Entitlement Manual, Chapter 4 - Physician Certification and Recertification of Services
- CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 1 - Inpatient Hospital Services Covered Under Part A
- CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 6 - Hospital Services Covered Under Part B
- CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Publication, Chapter 10 - Ambulance Services
- CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 15 - Ambulance
- CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 15 - Medicare Enrollment
- CMS IOM, Publication 100-16, Medicare Managed Care Manual, Chapter 4 - Benefit and Beneficiary Protections
- CMS Change Request (CR) 7363 - Additional Provider and Supplier Enrollment Requirements for Fixed Wing and Helicopter Air Ambulance Operators