Archived Policies - Administrative


Ambulance and Medical Transport Services

Number:ADM1001.005

Effective Date:11-01-1997

End Date:06-30-2004

Coverage:

Ambulance services are eligible for coverage when following guidelines as outlined below:

  • the patient's condition must be such that any other form of transportation would be medically contraindicated;
  • the patient is transported to the nearest site with the appropriate facilities for the treatment of the injury or illness involved; and
  • coverage will be extended to the next nearest facility generally equipped to provide the needed care, if

a) no bed is available,

b) a burn unit is required,

c) special diagnostic equipment is needed,

d) the trauma unit is full, or

e) a specialist or surgeon is not on call or is not available.

Air or sea ambulance services are eligible for coverage as outlined below:

  • the time needed to transport a patient by either basic or advanced life support land ambulance poses a threat to survival; or
  • the point of pick-up is inaccessible by land vehicle.

The following services, items, or conditions are not eligible for coverage:

  • ambulance services when the patient has been legally pronounced dead prior to the ambulance being summoned;
  • a separate charge for dispatch fee, lift off fee, night call, federal excise tax;
  • a separate charge for emergency;
  • ambulance waiting time;
  • reusable supplies or equipment, which are considered an integral part of the general ambulance services; and
  • services by an ambulance crew who do not transport a patient but only render aid (example: ambulance dispatched to scene of an accident and crew renders aid until a helicopter can be sent; ambulance dispatched and patient refuses care; or ambulance dispatched and aid only is rendered).

Non-emergency transports are defined as ambulance transports for a patient who has a medical problem requiring treatment in another location and is so disabled that the use of an ambulance is the only appropriate means of transfer. "Disabled" means the patient's physical condition limits his/her mobility and requires that the patient is unable to stand and sit unassisted or requires continuous life support systems.

Situations where non-emergency transportation may be medically necessary for the patient described above include:

  • transfer from a hospital to a renal dialysis center when the dialysis facility furnishes services to patients of the hospital on an outpatient basis,
  • round trip transportation from a skilled nursing facility to freestanding facilities such as:

a) renal dialysis facility,

b) radiation therapy center.

Transfers by "medical" vans or commercial transportation (such as physician owned limousines, public transportation, cabs, etc.) are not reimbursable.

Description:

Ambulance services involve the use of a specially designed and equipped automotive or other vehicle, licensed by the state, and regulated by local, state and federal laws, to transport the ill or injured. Ambulances can be classified as either basic life support or advanced life support depending upon how the vehicle is equipped. This in turn regulates the level of care that can be provided in the actual transport.

Rationale:

00None

Contract:

Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions. Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply. If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.

Coding:

The following services and supplies are not separately payable whether in an Advanced Life Support or Basic Life Support.  If any of these are billed, combine the charges with the ambulance base rate:

SUPPLIES:

  • Ammonia inhalant
  • Amyl Nitrate inhaler
  • Arm sling
  • Bio-Hazard supplies (e.g., red plastic bags)
  • Blue pads
  • Cervical collars
  • Disaster bag
  • Disaster pouch
  • Disposable CO2 detector (easy cap Nec-Loc)
  • Disposable gloves
  • Disposable gowns
  • Disposable Heat pads
  • Disposable infection kit
  • Disposable sheets
  • EKG paper
  • Emesis basin
  • Ice
  • Inflatable leg or arm splint
  • IV start kit
  • KY jelly
  • Lancet (box of 100)
  • Lure adapter
  • Mask or face shield
  • Needle monojet
  • Orthopedic equipment
  • Personal protection equipment
  • Sani-Liners
  • Suction bags
  • Suction liner
  • Surgical supply, miscellaneous
  • Vacutainer

SERVICES:

  • Administration of CPR
  • Air time
  • Decompression
  • External pacing
  • Intubation
  • IV Administration
  • IV insertion
  • Minor Extrication
  • Oxygen saturation
  • Intubation (the procedure)
  • Use of Accu-Chek or Glucometer
  • Use of AED - Auto defibrillator
  • Use of Ambu-bag
  • Use of blood pressure monitor
  • Use of Capnometer
  • Use of infusion pump
  • Use of invertor for monitor
  • Use of pulse oximeter
  • Use of resuscitator
  • Use of suction machine
  • Use of telemetry equipment
  • Use of thermometer
  • Use of Thumper
  • Venipuncture (the procedure)

REUSABLE SUPPLIES:

  • Back board
  • Linen
  • Mast anti-shock trousers
  • Neck board
  • Rescue blanket
  • Sand bags
  • Stylet

Air Ambulance: Reimbursement for transport includes lift off.  Allowances for mileage will continue to be based on loaded miles only.


Medicare Coverage:

None

References:

BCBSA Medical Policy Reference Manual, Introduction, 12/1/95, page 4.1997 Medicare Part B Specialty Workshops, Ambulance.

Policy History:

Archived Document(s):

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