· Nonemergency ambulance transportation: All Minnesota Health Care Programs (MHCP) members, EXCEPT those covered under the Emergency Medical Assistance (EMA) program being transported for services not related to their EMA-approved medical condition.

Covered Services

MHCP covers ambulance services when the member’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 member to another facility because the first facility could not provide the level of care required by the member. Includes emergency and nonemergency ambulance transport.

· Medically necessary and documented as defined in Minnesota Statutes, 144E.123, 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 member 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 on arrival

Transportation is not covered if a member is pronounced dead by a legally authorized person before transportation is called.

MHCP covers ambulance no-load transportation (when member is not transported) only if the ambulance transportation staff provided medically necessary treatment to the member at the pickup point.

Air Ambulance Guidelines

MHCP covers air ambulance when the following criteria are met:

· The member 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 member.

· Transportation is to the nearest appropriate facility capable of providing the level of care required by the member.

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.

If air ambulance transportation is used and documentation is not provided that shows the member meets the eligibility requirements under the Air Ambulance Guidelines, the claim will be denied. The claim must be resubmitted as ground ambulance transportation, or be resubmitted with proper documentation showing medical necessity. See Billing for instruction on how to submit air and ground ambulance transportation claims.

Ground Ambulance Guidelines

MHCP covers ground ambulance when the following criteria are met:

· The member has a potentially life-threatening condition that does not permit the use of another form of transportation.

· The service is medically necessary.

· The referring facility does not have adequate facilities to provide the medical services needed by the member.

· The transportation is to the nearest appropriate facility by the most direct route.

Noncovered Services

Refer to the Transportation Services Overview page for noncovered services.

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 members transported for more than six one-way trips (three round trips) during a 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 member requiring ambulance transport.

· 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

· 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 member. 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.

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.

Supplemental Payments

Providers who are eligible by legal statute are paid supplemental payments in addition to the payments already received for providing services on a fee-for-service basis to Medical Assistance (MA) members. The supplemental payments are computed annually and paid in one lump sum for each calendar year. See the Supplemental Payments – Non-Hospital and Hospital section of the MHCP Provider Manual for more information.

Definitions

Ambulance Service: The transport of a member 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.196, subdivision 2d – Supplemental Payments
Minnesota Statutes, 256B.0625, subdivision 17 – Transportation costs
Minnesota Statutes, 256B.0625, subdivision 17a – Payment for ambulance services
Minnesota Statutes, 256B.0625, subdivision 18 – Access to medical services
Minnesota Rules, 8840.5925 – Vehicle Equipment
Minnesota Rules, 9505.0315 – Medical Transportation
Minnesota Rules, 9505.0445 – Payment Rates
Code of Federal Regulations, title 42 431.53
Code of Federal Regulations, title 42 440.170 (a)

Report this page

Issue:
Email:
Comments: