Air and water ambulance vehicles are specially equipped to transport individuals with life threatening emergencies to the hospital.

Pennsylvania Mandate

Section 1.  Section 2116 of the act of May 17, 1921 (P.L.682, No.284), known as The Insurance Company Law of 1921, is amended to read:

Section 2116.  Emergency Services:

(a) If an enrollee seeks emergency services and the emergency health care provider determines that emergency services are necessary, the emergency health care provider shall initiate necessary intervention to evaluate and, if necessary, stabilize the condition of the enrollee without seeking or receiving authorization from the managed care plan. [The managed care plan shall pay all reasonably necessary costs associated with the emergency services provided during the period of the emergency.] The managed care plan shall pay all reasonably necessary costs associated with emergency services provided during the period of emergency, subject to all copayments, coinsurances or deductibles. When processing a reimbursement claim for emergency services, a managed care plan shall consider both the presenting symptoms and the services provided. The emergency health care provider shall notify the enrollee's managed care plan of the provision of emergency services and the condition of the enrollee. If an enrollee's condition has stabilized and the enrollee can be transported without suffering detrimental consequences or aggravating the enrollee's condition, the enrollee may be relocated to another facility to receive continued care and treatment as necessary.

(b)  For emergency services rendered by a licensed emergency medical services agency, as defined in 35 Pa.C.S. § 8103 (relating to definitions), that has the ability to transport patients or is providing and billing for emergency services under an agreement with an emergency medical services agency that has that ability, the managed care plan may not deny a claim for payment solely because the enrollee did not require transport or refused to be transported.

(c)  For emergency services provided to medical assistance participants, the following provisions shall apply:

(1) The provisions of subsection (b) shall apply to the same services provided to medical assistance participants under Article IV of the act of June 13, 1967 (P.L.31, No.21), known as the Human Services Code.

(2) Payment for the services shall be in accordance with the current managed care contracted rates.

(3) Sufficient funds shall be appropriated each fiscal year for payment of the services.

(d)  The provisions of subsection (b) shall apply to all group and individual major medical health insurance policies issued by a licensed health insurer.

Ambulance transportation is a benefit under many, but not all, of the Plan’s programs. 

When an individual has the ambulance benefit, coverage is made in accordance with all appropriate contractual provisions and limitations.

This policy addresses general guidelines applicable to air ambulance services. It should be used as a reference source in conjunction with the individual’s benefits, the network provider’s agreement with the Plan, and any applicable ambulance billing guidelines. This policy, the individual’s benefits, the network provider's agreement with the Plan, and any applicable ambulance billing guidelines are referred to in this policy as air ambulance criteria.

Air and water ambulance transportation may be considered medically necessary when ALL the following criteria are met: 

• The emergency transport vehicle must be specially designed and equipped for transporting the sick or injured; and
• It must have customary patient care equipment, supplies, and safety and lifesaving equipment; and
• The ambulance crew must consist of at least two (2) attendants. One (1) of these attendants must be duly qualified to provide the medical care required during transport; and
• The individual’s medical condition must require immediate and rapid transportation that cannot be provided by land ambulance; and 
• At least ONE of the following:
  • The point of pick-up is inaccessible by land vehicle (this condition could be met in Hawaii, Alaska, and in other remote or sparsely populated areas); or
  • Great distances or other obstacles (for example, heavy traffic) are involved in getting the individual to the nearest hospital with appropriate facilities for treatment. The term "appropriate facility” refers to a hospital that is capable of providing the required level and type of care for the individual’s illness and has available the type of physician or specialist needed to treat the individual’s condition.

Medical necessity for air or water transportation is established when the individual’s condition is such that the time needed to transport an individual by land (greater than 30 minutes), or the instability of transportation by land, poses a threat to the individual’s survival or seriously endangers the individual’s health.

Following is a list of examples of cases for which air or water ambulances could be justified; this list is not inclusive of all situations that justify air or water emergency transportation, nor is it intended to justify air or water emergency transportation in all locales for the circumstances listed.

• Intracranial bleeding which requires neurosurgical intervention; or
• Cardiogenic shock; or
• Major burns requiring treatment in a burn center; or
• Conditions requiring treatment in a hyperbaric oxygen unit; or
• Multiple severe injuries; or
• Life-threatening trauma; or
• Transplants; or
• High risk pregnancy – (high risk of preterm delivery or high medical risk to mother or fetus).

The vehicle and crew utilized for air or water ambulance transport must meet all applicable local, state, and federal regulatory certification and licensing requirements.

NOTE: The use of extra attendants is covered when an individual's benefit permits extra attendants.

The transfer of an individual from one hospital to another may be considered medically necessary if medical appropriateness criteria are met and the transferring hospital does not have adequate facilities to provide the medical services needed by the individual.

Examples of such services include:

• Burn units; or
• Cardiac care units; or
• Trauma units; or
• Transplant; or
• Severe rejection of transplant-to-transplant hospital.

The ambulance transport is covered ONLY if the hospital to which the individual is transferred is the nearest with appropriate facilities. 

Air and water ambulance transportation are considered not medically necessary when the above criteria have not been met.

NON-EMERGENCY TRANSPORT*

Non-emergency air or water ambulance services may be considered medically necessary when ALL of the following criteria are met:

• The individual's medical condition requires uninterrupted care and attendance by qualified medical staff during transport; and
• The individual's medical condition requires transport that cannot be provided by land ambulance; and
• Great distances, limited timeframes, or other obstacles are involved in transporting the individual; and
• The origin (point of pick-up) is an acute care facility (e.g., hospital, rehabilitation hospital) and is not otherwise precluded from eligibility in the individual’s contract; and
• ALL of the following destination criteria are met:
  • The destination is not precluded from eligibility in the individual’s contract; and
  • The destination has the appropriate facilities to treat the individual’s condition.

*Non-emergency air or water ambulance transport is NOT covered for the convenience of the individual, family members/companions, or the provider treating the individual.

Examples of non-covered air or water ambulance transportation:

• Air or water emergency transportation used to transport individual to a facility for treatment because family or individual wants treatment at that facility when there is an equally competent facility near individual; or
• Air or water transport utilized for an individual in a foreign country to transport home for treatment when same competent treatment could have been completed in the foreign country; or
• Air or water transport utilized for individual or family’s convenience in a non-life threatening circumstance.

Pronouncement of Death

Payment may be made for an air or water ambulance service when the air or water ambulance responds to pick up an individual, but the individual is pronounced dead before being loaded onto the ambulance for transport (either before or after the ambulance arrives on the scene).

• This is provided the air or water ambulance service would otherwise have been medically necessary.

In such a circumstance, the allowed amount is the appropriate air or water base rate, i.e., airplane, helicopter, or boat.

• However, no amount will be allowed for mileage that would have been allowed had the transport of a living individual been completed.

A pronouncement of death is valid only when made by an individual authorized under State law to make such a pronouncement.

Additionally, no payment is made if the dispatcher received pronouncement of death and had sufficient time to abort the transport. Further, no payment is made if an aircraft has merely taxied but not taken off or, at a controlled airport, has been cleared to take off but has not actually taken off.

Air or water ambulance companies must use the modifier QL (Individual pronounced dead after ambulance called) to indicate the circumstance when an air ambulance takes off to pick up an individual but the individual is pronounced dead before the pickup can be made.

• Air or water ambulance companies must maintain documentation, sufficient to show that:
  • The air or water ambulance was dispatched to pick up an individual; and
  • The aircraft or watercraft was in route to make the pickup; and
  • The individual to whom the dispatch relates was pronounced dead before being loaded onto the ambulance for transport; and
  • The pronouncement of death was made by an individual authorized by State law to make such a pronouncement; and
  • The dispatcher did not receive notice of such death pronouncement in sufficient time to permit the transport to be aborted before in route for pick-up. 

Additional air or water mileage or wait time may be allowed in situations where additional mileage or wait time is incurred due to circumstances beyond the ambulance pilot’s or captain’s control. These circumstances include, but are not limited to, the following: 

• Military base and other restricted zones, air-defense zones, and similar FAA restrictions and prohibitions; or
• Hazardous weather; or
• Variances in departure patterns and clearance routes required by an air traffic controller.  

If the air or water transport meets the criteria for medical necessity, claims for air or water transports may account for all mileage from the point of pickup including where applicable: ramp to taxiway, taxiway to runway, take-off run, air miles, roll out upon landing, taxiing after landing.

Additional Information

Ground to Air or Water Transport When an individual is transported by ground ambulance and transferred to an air or water ambulance, the ground ambulance may bill for the level of service provided and mileage from the point-of-pickup to the point-of-transfer to the air or water ambulance.

In these situations in which an individual is transported by ground ambulance to or from an air or water ambulance, the ground and air or water ambulance providers must bill independently. Payment will be made to each provider individually for its respective services and mileage.

Miscellaneous

• Air ambulance services are not covered for transport to a facility that is not an acute care hospital, such as a nursing facility, physician’s office or an individual’s home.
• More than one individual may be transported in the ambulance. The billed amount should be prorated by the number of individuals in the ambulance. 
• If a determination is made that the transport by an ambulance was necessary, but land ambulance service would have sufficed, payment for the air ambulance service should be based on the amount payable for land transport, if less costly..
• If the air transport was medically appropriate but the individual could have been treated at a nearer hospital than the one to which they were transported, the air transport payment is limited to the rate to the nearer hospital.