Covered Destinations for Ambulance Transportation

Basics of Destinations for Ambulance Transportation

Ambulance transport is covered to the nearest appropriate facility to obtain necessary diagnostic and/or therapeutic services such as a CT scan or cobalt therapy as well as the return transport. In addition to all other coverage requirements, this transport situation is covered only to the extent of the payment that would be made for bringing the service to the patient. Most of the insurance carriers cover ambulance transports to the destinations like hospitals; Critical Access Hospital (CAH); Skilled Nursing Facility (SNF); from an SNF to the nearest supplier of medically necessary services not available at the SNF; beneficiary’s home; dialysis facility for ESRD patient who requires dialysis. In this article, we will be understanding such covered destinations for ambulance transportation.

As a general rule, only local transportation by ambulance is covered, and therefore, only mileage to the nearest appropriate facility equipped to treat the patient is covered. However, if two or more facilities that meet the destination requirements can treat the patient appropriately and the locality of each facility encompasses the place where the ambulance transportation of the patient began, then the full mileage to any one of the facilities to which the beneficiary is taken is covered.

Covered Destinations for Ambulance Transportation

Institution to Beneficiary’s Home:

Ambulance service from an institution to the beneficiary’s home is covered when the home is within the locality of such institution or where the beneficiary’s home is outside of the locality of such institution but the institution, in relation to the home, is the nearest one with appropriate facilities.

Institution to Institution:

Occasionally, the institution to which the patient is initially taken is found to have inadequate or unavailable facilities to provide the required care, and the patient is then transported to a second institution having appropriate facilities. In such cases, transportation by ambulance to both institutions would be covered to the extent of the mileage to be the nearest institution with appropriate facilities. In these cases, transportation from such a second institution to the patient’s home could be covered if the home is within the locality served by that institution, or the locality served by the first institution to which the patient was taken.

Not Inpatients:

Ambulance transports to and from a covered destination (i.e., two 1-way trips) furnished to a beneficiary who is not an inpatient of a provider for the purpose of obtaining covered medical services are covered, if all program requirements for coverage are met. In addition, coverage of ambulance transports to and from a destination under these circumstances is limited to those cases where the transportation of the patient is less costly than bringing the service to the patient.

Appropriate Facilities:

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 or a physician specialist is available to provide the necessary care required to treat the patient’s condition. However, the fact that a particular physician does or does not have staff privileges in a hospital is not a consideration in determining whether the hospital has appropriate facilities. Thus, ambulance service to a more distant hospital solely to avail a patient of the service of a specific physician or physician specialist does not make the hospital in which the physician has staff privileges the nearest hospital with appropriate facilities.

Special Case Medicare Coverage

Transportation of a beneficiary from his or her home, an accident scene, or any other point of origin is covered under Medicare part B as an ambulance service only to the nearest hospital, critical access hospital (CAH), or skilled nursing facility (SNF) that is capable of furnishing the required level and type of care for the beneficiary’s illness or injury and only if medical necessity and other program coverage criteria are met. Ambulance transport from an SNF to the nearest supplier of medically necessary services not available at the SNF where the beneficiary is a resident and not in a covered Part A stay, including the return trip, is covered under Part B provided that the ambulance transportation was medically reasonable and necessary and all other coverage requirements are met.

Medicare-covered ambulance services are paid either as separately billed services, in which case the entity furnishing the ambulance service bills Part B of the program or as a packaged service, in which case the entity furnishing the ambulance service must seek payment from the provider who is responsible for the beneficiary’s care. If either the origin or the destination of the ambulance transport is the beneficiary’s home, then the ambulance transport is paid separately by Medicare Part B, and the entity that furnishes the ambulance transport may bill its A/B MAC (A) or (B) directly.

Medical Billers and Coders (MBC) is a leading medical billing company providing complete medical billing and coding services. We referred ‘Medicare Benefit Policy Manual Chapter 10’ to discuss covered destinations for ambulance transportation. For any assistance in ambulance transportation billing, email us at: info@medicalbillersandcoders.com or call us at: 888-357-3226.