Coverage Statement for temporary expansion of the list of allowable destinations for ground ambulance transports:
In accordance with the Centers for Medicare & Medicaid Services (CMS), the list of covered destinations for medically necessary ground ambulance transportation (emergency and nonemergency) from any point of origin will be expanded to include, but not limited to, any of the following:
Coverage Statement for ground ambulance services without a transport: In accordance with the Centers for Medicare & Medicaid Services (CMS), medically necessary ground ambulance services without transport will be covered when ALL of the following criteria are met:
- any location that is an alternative site determined to be part of a hospital, critical access hospital (CAH), or skilled nursing facility (SNF)
- community mental health centers
- federally qualified health centers (FQHCs)
- rural health clinics (RHCs)
- physician offices
- urgent care facilities
- ambulatory surgical centers (ASCs)
- any location furnishing dialysis services outside of an end stage renal disease (ESRD) facility when an ESRD facility is not available
- an individual's home
- The ground ambulance service was furnished in response to a 911 call (or the equivalent in areas without a 911 call system); and
- The individual would have been transported to a destination permitted under Medicare regulations, but the transport did not occur as a result of community-wide emergency medical service protocols due to the COVID-19 PHE; and
- The individual's condition required the level of service provided and would normally require transport by ambulance, absent the community-wide EMS protocols (in other words, any other means of transportation would have been contraindicated).
- Documentation establishes the community-wide EMS protocol was in effect for the area at the time ambulance services were provided to the individual.
BILLING REQUIREMENTS (for ground ambulance services without a transport)
Based on the level of service provided, claims should include one of the following HCPCS codes:
• A0429 (Ambulance service, basic life support, emergency transport (BLS-emergency))
• A0427 (Ambulance service, advanced life support, emergency transport, level 1 (ALS1)) AND
• A valid origin/destination modifier combination (in the first modifier position) that would have been appropriate if the individual had been transported
• The CR modifier to distinguish these waiver claims from other claims
Note: HCPCS codes for mileage should not be reported because no transport occurred.
The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.
The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.