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Minnesota Department of Human Services Provider Manual
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Ambulance Transportation Services

Revised: 01-13-2017

  • Overview
  • Eligible Providers
  • Eligible Recipients
  • Covered Services
  • Air Ambulance Guidelines
  • Ground Ambulance Guidelines
  • Noncovered Services
  • Authorization Requirements
  • Air Ambulance
  • Non-Emergency Ambulance Trips
  • Billing
  • Air Ambulance
  • Ground Ambulance
  • Definitions
  • Legal References
  • Overview

    Ambulance services include emergency and non-emergency ambulance services.

    Eligible Providers

    Eligible providers must be licensed as a transportation service provider for advanced life support, basic life support, or scheduled life support.

    Provider Type Home Page Links
    Review related Web pages for the latest news and additions, forms, and quick links.

    Eligible Recipients

    Eligible recipients for emergency and non-emergency transportation are as follows:

  • • Emergency ambulance transportation: All MHCP recipients
  • • Non-emergency ambulance transportation: Medical Assistance (MA), MinnesotaCare recipients under the age of 21 and pregnant MHCP recipients
  • Covered Services

    MHCP covers ambulance services when the recipient’s transportation is for the following:

  • • In response to:
  • • A 911 emergency call
  • • A police or fire department call
  • • An emergency call received by the provider
  • • Between two facilities, only when the first facility discharges the recipient to another facility because the first facility could not provide the level of care required by the recipient
  • • Medically necessary and documented as defined in Prehospital Care Data
  • • A transfer of an infant from an NICU level II or III nursery to a hospital near the family’s home, if the distance from the NICU facility to the family home is greater than 40 miles
  • Transportation is covered according to the following if a recipient is pronounced dead by a legally authorized person:
  • • After transportation is called, but before it arrives, service to the point of pickup is covered
  • • En route, or dead on arrival, the transportation is covered
  • • Before transportation is called, transportation is not covered
  • MHCP covers ambulance no-load transportation only if the ambulance transportation staff provided medically necessary treatment to the recipient at the pickup point.

    Air Ambulance Guidelines

    MHCP covers air ambulance when the following criteria are met:

  • • The recipient has a potentially life-threatening condition that does not permit the use of another form of ambulance transportation
  • • The referring facility does not have adequate facilities to provide the medical services needed by the recipient
  • • Transport must be to the nearest appropriate facility capable of providing the level of care required by the recipient
  • All air ambulance transportation originating outside of or going to a destination outside of Minnesota or its local trade area must receive authorization from the MHCP medical review agent. The Minnesota local trade area includes Minnesota and the counties of neighboring states that are contiguous with Minnesota.

    The conditions as indicated by the ICD CM codes are not in and of themselves a justification for payment. This list is not all-inclusive:

  • • Burns requiring treatment in a Burn Center
  • • Cardiogenic shock
  • • Conditions requiring treatment in a Hyperbaric Oxygen Unit
  • • Intracranial bleeding
  • • Multiple severe injuries
  • • Myocardial infarction
  • • Stroke
  • If medical necessity is not proven and proper documentation does not exist, air ambulance transportation for a recipient not having a potentially life-threatening condition will be denied and must be resubmitted as ground ambulance transportation.

    Ground Ambulance Guidelines

    MHCP covers ground ambulance when the following criteria are met:

  • • The recipient has a potentially life-threatening condition that does not permit the use of another form of transportation
  • • Service is medically necessary
  • • The referring facility does not have adequate facilities to provide the medical services needed by the recipient.
  • • Transport must be to the nearest appropriate facility by the most direct route
  • Noncovered Services

    Refer to the Transportation Services Overview page for noncovered services.

    Authorization Requirements

    Refer to the Authorization section for general authorization requirements.

    Ambulance Transportation Authorization Requirements

    Type of transportation

    Requirements

    Air ambulance

    All air ambulance transportation originating outside of Minnesota and its local trade area or going to a destination outside of Minnesota and its local trade area must receive authorization from the MHCP medical review agent. This requirement does not include to destinations or facilities located in neighboring states when the county of the neighboring state is contiguous to Minnesota.

    Nonemergency ambulance trips

    Request authorization from the MHCP/DHS medical review agent for nonemergency ambulance transports for recipients who will be transported for more than six one-way trips (three round trips) during a calendar month.

    Air Ambulance

    All air ambulance transportation originating outside of Minnesota or going to a destination outside of Minnesota must receive authorization from the MHCP medical review agent.

    Nonemergency Ambulance Trips

    Request authorization from the MHCP medical review agent for nonemergency ambulance transports for recipients who will be transported for more than six one-way trips (three round trips) during a single calendar month.

    Include the appropriate mileage code and total miles when requesting authorization for air or nonemergency transports.

    Billing

    Use the following information when billing for ambulance transportation services:

  • • Refer to the Billing Policy section for general MHCP billing policies
  • • Bill ambulance services according to Medicare guidelines. This includes entering a corresponding ICD CM code identifying the condition of the recipient requiring ambulance transport. The diagnosis code list will be updated with new diagnosis code information as needed
  • • Refer to the MN–ITS User Guide for Ambulance 837P or 837I (Outpatient)
  • • See the AUC guidelines for claim attachments
  • • Use the most appropriate ICD-10 code for dates of service on or after October 1, 2015
  • Use the HCPCS code that best describes the services rendered. The codes must reflect the level and type of service provided, not the type of vehicle used
  • • Use the HCPCS code that best describes emergency and nonemergency transportation following Medicare guidelines
  • • Use appropriate origin and destination modifier(s) on all base and mileage lines
  • • Submit separate claims for air and ground transport on the same date of service for the same recipient. Refer to the following:
  • • Air ambulance: Complete the Air Ambulance Billing Checklist (DHS-5208) (PDF) information
  • • Facility to facility: Complete either the Air Ambulance Billing Checklist or the Ground Ambulance Billing Checklist (DHS-5208A) (PDF) as appropriate. Enter the origin and destination facilities
  • Air Ambulance

    Submit the Air Ambulance Checklist (DHS-5208) (PDF) with all claims for air ambulance transports. If medical necessity is not proven and proper documentation does not exist, air ambulance transportation will be denied and must be billed as ground transportation.

    Ground Ambulance

    Submit the Ground Ambulance Billing Checklist (DHS-5208a) (PDF) information with ground ambulance claims when the “Origin” and “Destination” indicators (modifier) indicate the transport is from and to any of the following:

  • • Hospitals (HH)
  • • Skilled Nursing Facilities (NN)
  • • Residential, Domiciliary, or Custodial Facilities (EE)
  • • Diagnostic or Therapeutic Sites (DD)
  • • Hospital based ESRD facilities (GG)
  • • Freestanding ESRD facilities (JJ), also GJ and JG
  • • Site of Transfer to Site of Transfer (II)
  • Also note the following when billing for ground ambulance transport:

  • • Submit procedure code A0998 (ambulance response and treatment, no transport) without a modifier
  • Do not include the Ground Ambulance Billing Checklist information when billing A0998
  • Use the appropriate ambulance transport service code to indicate the level of ambulance transport service provided.
  • Definitions

    Ambulance Service: The transport of a recipient whose medical condition or diagnosis requires medically necessary services before and during transport.

    Neonatal intensive-care unit (NICU): A unit of a hospital specializing in the care of ill or premature newborn infants.

    Legal References

    Minnesota Statutes 144E.10 – Ambulance Service Licensing
    Minnesota Statutes 144E.16
    – Rules; Local Standards
    Minnesota Statutes 174
    – Department of Transportation
    Minnesota Statutes 256B.0625
    , subd.17 – Transportation costs
    Minnesota Statutes 256B.0625
    , subd. 17a – Payment for ambulance services
    Minnesota Statutes 256B.0625
    , subd.18 – Access to medical services
    Minnesota Rules 8840.5925
    – Vehicle Equipment
    Minnesota Rules 9505.0315
    – Medical Transportation
    Minnesota Rules 9505.0445
    – Payment Rates
    42 CFR 431.53
    42 CFR 440.170 (a)

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    © 2017 Minnesota Department of Human Services Updated: 1/13/17 3:24 PM | Accessibility | Terms/Policy | Contact DHS | Top of Page | Updated: 1/13/17 3:24 PM