Ground ambulance transportation is defined as ambulance services provided by a motor vehicle over roadways.

DELAWARE MANDATE:

18 Delaware Code Sections 3349, 3349A, 3367, 3565, 3565A and 3571H indicate that all individual and group health insurance policies shall provide that persons covered under those policies will be insured for emergency medical care services performed by non-network providers.  The Delaware Code also indicates that every individual health insurance policy, contract, certificate, or plan which is delivered or issued for delivery in the State of Delaware by any health insurer, health service corporation, health maintenance organization, or managed care organization shall include coverage of not less than the cost of every ambulance run and associated basic life support services provided by a volunteer ambulance company, however, the volunteer ambulance company must be certified by the Delaware State Fire Prevention Commission.

To be covered, ambulance transportation must be medically necessary. Medical necessity is established when the individual’s clinical condition is such that the use of any other method of transportation, such as taxi, private car, or other type of vehicle would be contraindicated (i.e., would endanger the patient's medical condition).

The individual’s condition at the time of the transport is the determining factor in whether a trip will be covered. The fact that the individual is elderly has a positive medical history, or cannot care for himself/herself does not establish medical necessity.

Additionally, stair safety concerns or the individual’s inability to negotiate stairs, in the absence of another medical condition that meets medical necessity criteria, does not satisfy medical necessity criteria.

Payment will not be made for ambulance service when an ambulance was used simply for convenience or because other means of transportation was not available.

Reimbursement may be made for expenses incurred by an individual for ambulance services that meet the following conditions (this is not an all-inclusive list):

• Was transported in an emergency situation, e.g., as a result of an accident, injury or acute illness; or
• Needed to be restrained; or
• Was unconscious or in shock; or
• Required oxygen (due to hypoxemia, syncope, airway obstruction or chest pain) or other emergency treatment on the way to the destination; or
• Had to remain immobile because of a fracture that had not been set or the possibility of a fracture (e.g., hip fracture, compound fracture, severe pain with need for intravenous pain medication or neurological injury); or
• Sustained an acute stroke or myocardial infarction; or
• Was experiencing severe hemorrhage; or
• Was bed confined before and after the ambulance trip (see note below); or
• Could be moved only by stretcher because of a specific physical condition or limitation; or
• Lower extremity contractures creating non-ambulatory status and the individual cannot sit in a wheelchair (severe fixed contractures proximal to the knee); or
• Severe generalized weakness from a health condition that would be exacerbated by transport in a vehicle other than an ambulance; or
• Severe vertigo causing inability to remain upright; or
• Immobility of lower extremities (Spica or full body cast, fixed hip joints or lower extremity paralysis and unable to be moved by wheelchair).

NOTE: Post-hip replacement individuals may sit in a chair slightly higher than the average seat. This condition alone does not satisfy the medical necessity requirement. Post-knee replacement individuals should be able to bend their knee approximately 90 degrees at the time of discharge. This condition alone does not satisfy the medical necessity requirement.

NOTE: "Bed confinement" is defined as (all three conditions must be met):

The individual is:

• Unable to get up from bed without assistance;
• Unable to ambulate; and
• Unable to sit in a chair or wheelchair.

Non-emergency ambulance transportation is not covered for individuals who are restricted to bed rest by a physician’s instructions but who do not meet the above three criteria. If some means of transportation other than an ambulance (i.e., private car, wheelchair van, etc.) could be utilized without endangering the individual’s health, regardless if such other transportation is actually available, no payment may be made for ambulance service.

Vehicle and Crew Requirement

Any vehicle used as an ambulance must be designed and equipped to respond to medical emergencies, and, in non-emergency situations, be capable of transporting individuals with acute medical conditions. The vehicle and crew utilized for ambulance transport must comply with state or local laws governing the licensing and certification of an emergency medical transportation. At a minimum, the ambulance must contain a stretcher, linens, emergency medical supplies, oxygen equipment, and other lifesaving emergency medical equipment and be equipped with emergency warning lights, sirens, and telecommunications equipment as required by state or local law. This should include, at a minimum, one two-way voice radio or wireless telephone.

If the previous criteria are not met, the service will be denied as non-covered. A network provider can bill the member for the non-covered service.

Destination Requirements
For an ambulance trip to be covered, the individual must be transported to the closest local facility that has appropriate facilities for treatment. The term "appropriate facilities" means that the institution is generally equipped to provide the needed hospital or skilled nursing care for the illness or injury involved. In the case of a hospital, it also means that a physician is available to provide the necessary care required to treat the individual’s condition.

Pronouncement of Death
No payment will be made if the individual was pronounced dead prior to the time the ambulance was called. The following scenarios apply to payment for ambulance services when the individual dies:

• If the individual is pronounced dead after the ambulance is called (before or after the ambulance arrives at the scene), but before they are loaded onboard the ambulance:
  • Payment may be made for a BLS base rate; no mileage adjustment will be made. Use the QL modifier ( individual pronounced dead after the ambulance was called); or
• If the individual is pronounced dead after being loaded into the ambulance (regardless of whether the pronouncement is made during or subsequent to the transport):
  • Payment is made following the usual rules of payment as if the individual had not died. This scenario includes a determination of "dead on arrival" (DOA) at the facility to which the individual was transported.

NOTE:

Notwithstanding the individual’s apparent condition, the death of a individual should be recognized only when the pronouncement of death is made by an individual who is licensed or otherwise authorized under state law to pronounce death in the state where such pronouncement is

ALS and BLS Contractual Agreements
In situations where a BLS (Basic Life Support) supplier provides the transport of the individual and an ALS (Advanced Life Support) supplier provides a service that meets the definition of ALS intervention (e.g., ALS assessment, Paramedic Intercept services), the BLS supplier may bill the higher ALS rate, only if there is a written agreement between the BLS and ALS suppliers. Suppliers must provide a copy of the agreement or other such evidence (e.g., signed attestation) upon request.

No Transport
If no transport of a individual occurs no covered service is rendered. Therefore, payment will not be made to the ambulance company. This applies to situations in which the individual refuses to be transported, even if medical services are provided prior to loading the individual onto the ambulance (e.g., BLS or ALS assessment). A network provider can bill the member for this denied service.

Paramedic Intercept
Paramedic intercept services are ALS services provided by paramedics who are not part of the ambulance entity that is providing the actual patient transportation. Payment may be made for medically necessary paramedic intercept services.

Ambulance Transportation Services
Reimbursement for all ambulance suppliers will be based on a base rate for transportation, which includes all supplies. A separate charge is payable for mileage.

Ambulance suppliers should report one charge reflecting all services and supplies, with a separate charge for mileage. Codes that can be reported are:

Other services billed in addition to the base rate will be denied as an integral part of the actual transportation. They include the following codes: 

 Miscellaneous

• Individual procedure codes for service and mileage, along with the number of miles, must be reflected on the claim.
• Ambulance suppliers are required to retain documentation on file supporting all ambulance services (i.e., trip sheets).
• When multiple units respond to a call for services, payment will be made to the entity that provides the transport for the individual.  The transporting entity should bill for all services furnished.
• More than one individual may be transported, e.g., from the scene of a traffic accident. The billed amount should be prorated by the number of individuals in the ambulance.
• When multiple individual transports are reported, the statement "multiple patients" and the number transported must be documented.
• Based upon the state licensure requirements for an ambulance vehicle and crew members, cardiac monitoring is considered an ALS specialized service. Therefore, it is not recognized as a service performed in conjunction with a BLS transport.
• Payment will not be made for ambulance services that are provided for individual or family convenience.
• Payment will not be made for ambulance night differential charges for ambulance transport provided between the hours of 7pm and 7am (A0999), as it is considered an inherent part of the base rate for ambulance transport. Code A0999 will be denied as not covered when submitted for ambulance night differential charges for ambulance transport. A network provider cannot bill the member for the non-covered service.

Refer to medical policy Q-5 Ambulance Services: Air and Water for additional information.

NOTE:

Coverage for Ambulance Services is determined according to individual or group customer benefits.

Coverage for wheelchair van transport (A0130) and stretcher van transport (T2005, T2049) is determined according to the member's benefits and, where applicable, the network provider's agreement.

Services that do not meet the criteria of this policy will not be considered medically necessary. A network provider cannot bill the member for the denied service unless: (a) the provider has given advance written notice, informing the member that the service may be deemed not medically necessary; (b) the member is provided with an estimate of the cost; and (c) the member agrees in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.

A network provider can bill the member for the non-covered service.