This version of the policy will become effective 01/01/2020.
In consideration of the Commonwealth of Pennsylvania's mandate (Act 103 of 2018), this policy was updated to reflect a change in coverage position for emergency ambulance response and treatment, no transport. These services have been changed from being designated as a benefit exclusion to being medically necessary with criteria.
The following criteria have been added to this policy for Emergency Ground Ambulance Services Without Transportation:
For members enrolled in Pennsylvania products who are subject to the Commonwealth of Pennsylvania's mandate (Act 103 of 2018), emergency ground ambulance services without transportation is a covered service when ALL of the following medical necessity criteria are met:
When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.
This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.
D Diagnostic or therapeutic site other than P or H when these are used as origin codes
E Residential, domiciliary, custodial facility (other than 1819 facility)
G Hospital based ESRD facility
I Site of transfer (e.g. airport or helicopter pad) between modes of ambulance transport
J Freestanding ESRD facility
N Skilled nursing facility
P Physician’s office
S Scene of accident or acute event
X Intermediate stop at physician’s office on way to hospital (This is a destination code only)