HI 00610.250 Ambulance Service
An ambulance is a specially designed or equipped automobile or other vehicle (in some areas of the United States this might be a boat or plane) for transporting the sick or the injured. It must have customary patient care equipment including a stretcher, clean linens, first aid supplies, oxygen equipment, and such other safety and livesaving equipment as is required by State or local authorities.
The ambulance crew must consist of at least two members. Personnel whose duties involve the care or handling of the patient while providing ambulance service must have adequate training in the application of first aid. The driver would not have to meet this requirement if there is at least one other person assigned to the ambulance who has had the required training.
Carriers determine whether suppliers of ambulance services, other than participating providers (hospitals, SNF's and HHA's), meet the requirements.
B. Coverage requirements
For ambulance services to be covered, each of the following conditions must be met:
The vehicle utilized and the ambulance personnel whose duties involve care of the individual to be transported by the ambulance meet the requirements specified in A. above;
Ambulance service is covered only where the use of any other method of transportation is medically contraindicated by the patient's condition. (In any case, in which some means of transportation other than an ambulance could be utilized without endangering the individual's health, whether or not such transportation is actually available, no payment can be made for ambulance service.); and
The patient must have been transported to the nearest hospital with appropriate facilities or to one in the same locality, and under similar restrictions, from one hospital to another, or to an SNF.
Ambulance service from an institution to the beneficiary's home is covered when his home is within the locality of the institution from which he was being transported or where the beneficiary's home is outside of the locality of the institution and the institution in relation to his home is the nearest one with appropriate facilities.
The above requirement is intended to provide coverage of essential ambulance service without imposing arbitrary “mileage” limitations. Full reimbursement will not be made for ambulance services that involve transporting the patient beyond the locality except where he is transported to the nearest institution with appropriate facilities.
Partial reimbursement may be made for otherwise covered ambulance service which exceeded the above limits. Payment is based on the amount that would have been payable had the patient been transported from the pickup point to the nearest appropriate facility. However, when the beneficiary was transported from a distant hospital or a skilled nursing home to his residence, payment is based on the amount that would have been payable had the beneficiary been transported to his residence from the nearest institution with appropriate facilities.
The term “locality” means the service area surrounding the institution from which individuals normally come or are expected to come for hospital or skilled nursing facility services.Example:Mr. Trout becomes ill at home and requires ambulance service to the hospital. The small community in which he lives has a 35-bed hospital. Two large metropolitan hospitals are located some distance from Mr. Trout's community but they regularly provide hospital services to the community's residents. Mr. Trout's residence is within the “locality” of the metropolitan hospitals and direct ambulance service to either of these (and the local community hospital) is covered in full.
D. Appropriate facilities
The term “appropriate facilities” means that the institution is generally equipped to provide the needed hospital or skilled nursing care for the type of illness or injury involved.
The fact that a more distant institution is better equipped, either qualitatively or quantitatively, to care for the patient does not warrant a finding that a closer institution does not have “appropriate facilities.”
An institution is not considered an appropriate facility if there is no bed available. (The carrier presumes that there are beds available unless the claimant furnishes evidence that none of the local institutions had a bed available at the time the ambulance service was provided.)
Although ambulance service to a physician's office is not covered, there may be situations when in the course of transporting a beneficiary to a hospital, the ambulance stops at the physician's office because of the patient's dire need for professional attention and immediately thereafter continues on to the hospital. Payment may be made for the entire trip.
Transportation by ambulance to a hospital or SNF to obtain home health services not available to the beneficiary in his home is covered only if the conditions in B. above are met.
E. Foreign ambulance service
Effective with 1/1/73, payment can be made for necessary ambulance services which are furnished in connection with and during a period of covered foreign hospitalization.
In cases involving foreign ambulance services, the general requirements in A.-D. are also applicable, subject to the following special rules: If the foreign hospitalization was determined to be covered on the basis of emergency services the necessity requirement in B.2. and the destination requirement in B.3. are considered met.
F. Round-trip for specialized services
(Effective with services furnished on or after March 15, 1978). Round-trip ambulance services are covered if a hospital inpatient goes to another hospital to obtain necessary specialized diagnostic and/or therapeutic services (such as a CT scan or cobalt therapy) and the following requirements are met:
The patient's condition is such that use of any other method of transportation is contraindicated and;
The service are not available in the hospital in which the individual is an inpatient; and
The hospital furnishing the services is the nearest one with such facilities.
G. Transportation to a renal dialysis facility located on the premises of a hospital
A renal dialysis facility may be approved to participate in the endstage renal disease program as a part of a hospital or as a nonprovider. When approved as a part of a hospital, the facility meets the destination requirements of an institution. When approved as a nonprovider, the facility meets the destination requirements for purposes of ambulance service coverage under the following circumstances:
The facility is located on, or adjacent to, the premises of a hospital;
The facility furnishes services to patients of the hospital referred to in 1., e.g., on an out-patient or emergency basis, even though it is primarily in operation to furnish dialysis services to its own patients; and
There is an ongoing professional relationship between the two facilities. For example, the hospital and the renal dialysis facility have an agreement that the physician staff of the renal dialysis facility will abide by the by-laws and regulations of the hospital's medical staff.
A beneficiary receiving maintenance dialysis on an outpatient basis is not ordinarily ill enough to require ambulance transportation for dialysis treatment. If a claim for ambulance services furnished to a maintenance dialysis patient does not show that the patient's condition required ambulance service, it will be disallowed. However, if the documentation shows that ambulance service was required, the carrier determines whether the dialysis facility meets the destination requirements described above.