Ambulance Coverage Requirements

Access the below ambulance covearge related information from this page.

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
  • Point of pickup is inaccessible by ground vehicle
  • Great distances or other obstacles are involved in getting patient to nearest hospital with appropriate facilities

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

  • A PCS is a written form, which must be dated no earlier than 60 days before date service is furnished, for non-emergency scheduled or non-scheduled repetitive transports. It does not, in and of itself, demonstrate that a transport is medically reasonable and necessary. All appropriate documentation must be retained on file for such transports furnished and present it to Medicare upon request. It may be used to assess, among other things, whether the transport meets medical necessity, eligibility, coverage, benefit category, and any other criteria necessary for payment. See 42 CFR 410.40(d)

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

 

Last Updated Fri, 26 Mar 2021 15:21:55 +0000