What Makes Ambulance Transportation Facility Limit to Provide Care?

An ambulance can be termed as “Intensive Care Unit” offering immediate medical care to the ailing patient till he/she reaches the hospital. Ambulance transportation plays a crucial role however, as per Medicare Part B – Medical insurance only covers emergency and non-emergency ambulance transportation but it’s important to understand the exceptions and the costs.

While the denial can always be overturned, the current backlog of Medicare hearings means that getting the denial overturned could potentially take years.

Medicare will only cover ambulance services to the nearest appropriate medical facility that’s able to give you the care you need. If you choose to be transported to a facility farther away, Medicare’s payment will be based on the charge to the closest appropriate facility. If no local facilities are able to give you the care you need, Medicare will pay for transportation to the nearest facility outside your local area that’s able to give you necessary care hence ambulance transportation failing to provide the limited care.

What Is Ambulance Emergency Services

Medicare Part B covers emergency ambulance services and, in limited cases, non-emergency ambulance services. Medicare considers an emergency to be any situation when your health is in serious danger and you cannot be transported safely by other means. If your trip is scheduled when your health is not in immediate danger, it is not considered an emergency.

  • An ambulance is medically necessary, meaning it is the only safe way to transport you
  • The reason for your trip is to receive a Medicare-covered service or to return from receiving care
  • You are transported to and from certain locations, following Medicare’s coverage guidelines
  • And, the transportation supplier meets Medicare ambulance requirements
  • To be eligible for coverage of non-emergency ambulance services, you must:

Be confined to your bed or unable to get up from bed without help, unable to walk, and unable to sit in a chair or wheelchair.

Or, need vital medical services during your trip that are only available in an ambulance, such as administration of medications or monitoring of vital functions. Furthermore, Medicare never covers ambulette services. An ambulette is a wheelchair-accessible van that provides non-emergency transportation. Medicare also does not cover ambulance transportation just because you lack access to alternative transportation.

With the ever-evolving medical billing and coding rules, you know that you’ll be chipping in on the cost as well. So how much would you have to pay? If Medicare agrees that it will cover the trip, your portion will be 20 % of the Medicare-approved amount after you’ve met the yearly Part B deductible. All ambulance companies must accept the Medicare-approved amount as payment in full.

When Does Medicare Cover When It Comes To Ambulance Service?

Emergency Services

Medicare Part B Covers Ambulance Services To Or From:

  • A Hospital
  • A Critical Access Hospital
  • A Skilled Nursing Facility
  • Dialysis Facility
  • Although A Physician’s Office Is Not A Covered Destination, A Temporary Stop May Be Covered Without Affecting The Coverage Status

Transportation, when Medicare covers it, is only to the nearest appropriate medical facility that’s able to give you the care you need. So for instance, if you have an emergency but don’t wish to go to hospital A, but it is closer to where you are at the time of the emergency than hospital B, Medicare will cover transportation to hospital A.

If you choose to go to hospital B, Medicare will make a payment based on the charge for transportation to hospital A and leave you with the remainder of the bill. If no local facility exists, Medicare will pay for transportation to the nearest facility outside your local area that can provide appropriate care.

Non-Emergency Ambulance Services

Medicare considers situations when your health is in serious danger and every second counts to prevent your health from getting worse as an emergency. We may think of ambulance transportation as a response to an immediate crisis but, there are other times transportation by ambulance might be required and thus paid for by Medicare. When your life is not in danger, Medicare coverage of ambulance service is very limited.

Non-emergency ambulance transportation may meet Medicare’s requirements if such transportation is needed to obtain treatment like dialysis or to diagnose your health condition and any other type of transportation would endanger your health. A written order from your doctor must state that ambulance transportation is necessary due to your medical condition.

Because of the absence of specific communications, Medicare may eventually deny the claim. Such cases can be won on appeal but as pointed out at the beginning of this article fixing the error could conceivably take years.

To avoid such a situation discuss transportation options with a doctor or nurse prior to transport. If you are not bed-confined, consider other forms of transportation. If transportation by ambulance is necessary, request that the doctor or nurse communicate the reasons clearly to the ambulance crew so their documentation will reflect the need.

If Medicare doesn’t cover an ambulance trip you believe should be covered, carefully review your Medicare Summary Notice and any other paperwork related to your ambulance bill for errors in the paperwork that can be fixed. If Medicare doesn’t cover the trip and you believe it should, you have the right to appeal the decision.