Ambulance - TMHP

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					                                                                                                                                       Section

9   Ambulance
                                                                                                                                        9
9.1 Enrollment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   9-2
    9.1.1 Medicaid Managed Care Enrollment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                     9-2
9.2 Reimbursement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .        9-2
9.3 Benefits and Limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .         9-2
    9.3.1 Prior Authorization. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .         9-2
    9.3.2 Emergency Ambulance Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                   9-2
        9.3.2.1 Emergency Transport Billing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                  9-3
    9.3.3 Nonemergency Ambulance Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                      9-3
        9.3.3.1 Nonemergency Ambulance Transports. . . . . . . . . . . . . . . . . . . . . . . . . . .                           9-3
        9.3.3.2 Nonemergency Ambulance Transport Prior Authorization . . . . . . . . . . . . . .                                 9-4
        9.3.3.3 Prior Authorization Process. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                 9-4
        9.3.3.4 Authorization of Retroactive Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . .                   9-4
        9.3.3.5 Prior Authorization Types, Definitions . . . . . . . . . . . . . . . . . . . . . . . . . . .                     9-4
        9.3.3.6 Supporting Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                   9-5
    9.3.4 Claim Denials and Appeals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                9-5
    9.3.5 Ambulance Disposable Supplies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                    9-5
    9.3.6 Oxygen. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .      9-5
    9.3.7 Waiting Time . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .         9-5
    9.3.8 Extra Attendant or Registered Nurse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                   9-6
    9.3.9 Night Call . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .     9-6
9.4 Membership Fees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .          9-6
9.5 Types of Transport . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .       9-6
    9.5.1 Multiple Client Transports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .             9-6
    9.5.2 Out-of-Locality Transports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .             9-6
    9.5.3 Air or Boat Transports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .           9-6
    9.5.4 Pregnancy Transports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .             9-6
    9.5.5 Transports to or From State Institutions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                   9-6
    9.5.6 Transports for Nursing Facility Residents . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                    9-7
    9.5.7 No-Transport. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .        9-7
9.6 Medicare/Medicaid Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .               9-7
    9.6.1 Medicare Paid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .          9-7
    9.6.2 Medicare Denied . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .            9-7
9.7 Relation of Service to Time of Death . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .               9-7
9.8 Ambulance Procedure Codes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .               9-8
9.9 Claims Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .       9-8
    9.9.1 Modifiers on Ambulance Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .                  9-8
    9.9.2 Claim Filing Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .             9-8
Section 9


9.1 Enrollment                                                 For air transportation, providers must bill either with
                                                               procedure codes A0430 and A0435, or A0431 and
To enroll in the Texas Medicaid Program, ambulance             A0436. Providers must bill the appropriate mileage with
providers must operate according to the laws, regulations,     the appropriate base rate procedure code.
and guidelines governing ambulance services under
Medicare Part B; equip and operate under the appropriate       When submitting a claim for water transport services,
rules, licensing, and regulations of the state in which they   providers are to use procedure code A0999. The claim
operate; acquire a license from the Texas Department of        suspends for manual review and pricing.
State Health Services (DSHS), approving equipment and          Night calls are no longer paid separately.
training levels of the crew; and enroll in Medicare.
                                                               The payment rates represent a global payment. It is
A hospital-operated ambulance provider must be enrolled        inappropriate to bill for any supplies or other services
as an ambulance provider and submit claims using the           related to the transport, unless otherwise specified in this
ambulance Texas Provider Identifier (TPI), not the hospital    section.
TPI (see “Medicare/Medicaid Coverage” on page 9-7).
                                                               The integrity of the information regarding the client’s
Reminder: When ambulance providers enroll in Medicaid,         condition requiring the transport and the medical
they accept Medicaid payment as payment in full. They          necessity of the transport are the responsibility of the
cannot bill clients for Texas Medicaid-covered benefits.       ambulance provider. The ambulance provider may be
Refer to: “Provider Responsibilities” on page 1-4 for more     sanctioned, including exclusion from the Medicaid Title
          information about enrollment procedures.             XIX programs, for completing or signing a claim form that
                                                               includes false or misleading representations of the
                                                               client’s condition or the medical necessity of the
9.1.1 Medicaid Managed Care Enrollment                         transport.
Certain providers may be required to enroll with a
Medicaid Managed Care health plan to be reimbursed for         9.3.1 Prior Authorization
services provided to Medicaid Managed Care clients.
Contact the individual health plan for enrollment              All nonemergency transports require prior authorization.
information.                                                   Emergency transports do not require prior authorization.
                                                               However, all out-of-state (air and ground) transports
Note: Services for STAR+PLUS Program Medicaid                  require authorization before the transport is considered
Qualified Medicare Beneficiaries (MQMBs) must be prior         for payment.
authorized and processed by TMHP.
                                                               To initiate the prior authorization process, providers are to
Refer to: “Managed Care” on page 7-1 for more                  call 1-800-925-9126 (toll-free; from 7 a.m. to 7 p.m.,
          information.                                         Monday through Friday, Central Time) before the transfer
                                                               or on the first workday following transfers that occur after
                                                               hours, on weekends, or on holidays.
9.2 Reimbursement                                              TMHP is responsible for processing prior authorization
Ambulance services are reimbursed according to a               requests for all Medicaid clients, Primary Care Case
reasonable charge payment methodology in accordance            Management (PCCM) clients, and all STAR+PLUS
with Title 1 Texas Administrative Code (TAC) §355.8600.        MQMBs.
Ambulance providers are reimbursed for the transport
plus mileage.
                                                               9.3.2 Emergency Ambulance Services
Refer to: “Reimbursement” on page 2-2 for more infor-          According to 1 TAC §354.1111, an emergency transport
          mation about reimbursement methodologies.            is a service provided by a Medicaid-enrolled ambulance
            “Medicaid Program Limitations and Exclusions”      provider for a Medicaid client whose condition meets the
            on page 1-15 for information on Medicaid           definition of an emergency medical condition. Conditions
            exclusions.                                        requiring cardio pulmonary resuscitation (CPR) in transit or
                                                               the use of above routine restraints for the safety of the
                                                               client or crew are also considered emergencies. Facility-to-
9.3 Benefits and Limitations                                   facility transfers are appropriate as emergencies if the
                                                               required emergency treatment is not available at the first
Medicaid reimburses for emergency and nonemergency             facility.
(for the severely disabled) transports.
                                                               Examples of conditions considered for emergency trans-
For ground transportation, providers must bill procedure       ports include, but are not limited to, acute and severe
codes A0428 and A0425, or A0429 and A0425 with                 illnesses, untreated fractures, loss of consciousness,
modifier ET. Providers must bill the appropriate mileage       semiconsciousness, seizure or with receipt of CPR during
with the appropriate base rate procedure code.                 transport, acute or severe injuries from auto accidents,
                                                               and extensive burns.




9–2
                                                                                                                   Ambulance


Emergencies include medical conditions for which the           All claims submitted on paper or electronically must
absence of immediate medical attention could reasonably        include the two-digit origin and destination codes. The
be expected to result in serious impairment, dysfunction,      origin is the first digit, and the destination is the second
or failure of one or more organs or body parts, and the        digit. The following are the origin and destination codes
required emergency treatment is not available at the first     accepted by the Texas Medicaid Program:
facility. Claims for such transports must document the
                                                                Origin and Destination Codes
aforementioned criteria.
                                                                D       E          G          H          I          J
Emergency transports do not require prior authorization.
                                                                N       P          R          S          X
9.3.2.1 Emergency Transport Billing
When billing emergency transports electronically, a            9.3.3 Nonemergency Ambulance Services
minimum of one diagnosis description or the International
                                                               According to 1 TAC §354.1111, nonemergency transport
Classification of Diseases, Ninth Revision, Clinical Modifi-
                                                               is defined as a transport to or from a medical appointment
cation (ICD-9-CM) diagnosis code must be written on the
                                                               for a Medicaid client who requires treatment in another
claim form or in the diagnosis code field for electronic
                                                               location and is so severely disabled that the use of an
billers. A claim that has “see attached” as the only infor-
                                                               ambulance is the only appropriate means of transport.
mation in the diagnosis block is not processed for
payment consideration.                                         Severely disabled is defined as the physical condition of a
                                                               Medicaid client that limits mobility and requires the client
Important: Emergency transports that are denied cannot
                                                               to be bed-confined at all times, unable to sit unassisted
be accepted on appeal as nonemergency transports.
                                                               at all times, or requires continuous life-support systems
Note: Emergency and nonemergency claims may be billed          (including oxygen or intravenous infusion).
electronically to Medicaid. For electronic billers, the
                                                               A round-trip transport from the client’s home to a
hospital’s TPI must be entered in the facility ID field.
                                                               scheduled medical appointment (for example, an outpa-
Providers should consult with their software vendor for the
                                                               tient or freestanding dialysis or radiation facility) is a
location of this field on the electronic claim form.
                                                               covered service when the client meets the definition of
All emergency claims submitted on paper are required to        severely disabled. All nonemergency ambulance transfers
have the following documentation:                              to a scheduled doctor’s appointment require the doctor’s
                                                               name and address, the diagnosis, and the treatment                9
• Distance of transport traffic patterns
                                                               rendered at the time of visit.
• Time of transport
                                                               Nonemergency transports of clients with conditions that
• Acuity of client                                             do not meet the severely disabled criteria and are not prior
Place of Service Codes                                         authorized are not a covered Medicaid service.
National place of service codes 41 and 42 are accepted         Refer to: “Medical Transportation” on page I-1 for more
by the Texas Medicaid Program.                                           information about nonemergency transportation.
Condition Codes
Electronic billers should use as many Condition Codes as       9.3.3.1 Nonemergency Ambulance Transports
needed to fully describe the patient’s condition.              Medicaid health care providers (for example, physicians,
The following condition codes are accepted by the Texas        hospitals, nursing facilities) are responsible for providing or
Medicaid Program:                                              arranging nonemergency transportation for their severely
                                                               disabled Medicaid clients. Arranging nonemergency trans-
 Condition Code
                                                               portation for these clients is required by the Medicaid
 01            02         03          04          05           program and includes obtaining prior authorization for the
 06            07         08          09          60           transport. Health care providers must request prior autho-
                                                               rization before contacting the ambulance provider for the
Condition Code 60 is used to notify TMHP that the patient      transport.
was taken to the nearest facility.
                                                               Note: Ambulance providers may choose to bill healthcare
Origin and Destination Codes                                   providers who fail to provide appropriate authorization (the
Emergency transports billed as nonemergency services           prior authorization number) for nonemergency transports.
are denied. These transports may be appealed as                Ambulance providers may assist hospitals, physicians,
emergency claims only.                                         and other healthcare providers in obtaining prior
                                                               authorizations.
                                                               Providers may contact the TMHP Ambulance Unit at
                                                               1-800-925-9126 or their provider relations representative
                                                               with questions about the nonemergency ambulance
                                                               transport policy. To request prior authorization for a
                                                               nonemergency transport, providers are to fax the request
                                                               to the TMHP Ambulance Unit at 1-512-514-4205.


                                                                                                                          9–3
Section 9


9.3.3.2 Nonemergency Ambulance Transport Prior                 2) TMHP reviews all information and documentation
Authorization                                                     received and a letter of approval or denial is faxed to
Prior authorization is required for all nonemergency              the requesting provider. The client is notified by mail
ambulance transports. TMHP responds to prior authori-             if the authorization request is denied or downgraded.
zation requests within 48 hours of receipt of the request.        Reasons for denial include documentation that does
It is recommended that all requests for a prior authori-          not meet the severely disabled criteria or the client is
zation number (PAN) be submitted in sufficient time to            not eligible for the dates of services requested.
allow TMHP to issue the PAN before the date of the                Clients may appeal prior authorization request
requested transport. Documentation of a client’s                  denials by contacting TMHP Client Notification at
condition that meets the severely disabled definition must        1-800-414-3406.
be provided at the time of request. Prior authorization is a   3) The requester contacts the transporting ambulance
condition for reimbursement but is not a guarantee of             company and provides the company with the (PAN)
payment. The client and provider must meet all the                and the dates of service approved.
Medicaid requirements such as eligibility and filing           4) Ambulance providers must attempt to obtain the PAN
deadlines.                                                        before transporting the client. Claims submitted
These prior authorization requirements also apply to              without the PAN are denied and must be appealed in
Medicaid providers participating in PCCM. Medicaid                writing by the provider. The appeals must be accom-
providers participating in one of the Medicaid managed            panied by supporting documentation. The ambulance
care HMO plans must follow the requirements of their              provider must document attempts to obtain the PAN
plan.                                                             from the client or the health care provider before
Prior authorizations for nonemergency transports require          transporting the client. When the ambulance provider
supporting documentation. The TMHP Ambulance Unit                 is unable to obtain the PAN, the provider can do one
reviews the documentation to determine if the client              of the following:
meets the definition of severely disabled. Incomplete infor-       •    Transport the client and appeal the denied claim
mation may cause the request to be denied.                              with documentation of severe disability and
The following information assists TMHP in determining the               evidence of a previous and timely PAN request
appropriateness of the transport:                                  •    Transport the client and bill the healthcare
• A detailed explanation of the severity of the client’s                provider who failed to provide the appropriate
  physical condition that established the medical                       authorization
  necessity for transport. If the client is bed-confined,      5) Hospitals may call TMHP at 1-800-925-9126 or fax
  documentation must clearly state the reasons for the            to 1-512-514-4205 to obtain a PAN when discharging
  confinement                                                     a client or transporting the client to another facility.
• The necessary equipment, treatment, or personnel                Ambulance companies may provide documentation
  used during the transport                                       to assist hospitals in obtaining authorization, by fax
                                                                  only.
• The origination and destination points of the client’s
  transport                                                    Important: Claims submitted without the PAN are denied
                                                               and must be appealed by the provider.
Important: TMHP continues to require prior authorization
for all out-of-state ambulance transfers.
                                                               9.3.3.4 Authorization of Retroactive Eligibility
When the client does not meet the severely disabled
criteria, nonemergency ambulance services are not              Prior authorization is issued to clients who meet Medicaid
covered.                                                       eligibility and the severely disabled criteria. If a request for
                                                               a PAN is received and the client’s Medicaid coverage is
                                                               pending, the request will be denied. The client’s eligibility
9.3.3.3 Prior Authorization Process                            may be granted retroactively. The requestor has 95 days
Medicaid health care providers and TMHP follow the             from the date the eligibility is added to TMHP’s files to
following prior authorization process:                         contact the Ambulance Unit and request authorization to
                                                               be reconsidered.
1) The ambulance provider seeks prior authorization for
   a nonemergency transport. The client’s physician,           To inquire about Medicaid eligibility, providers are to
   nursing or ICF-MR facility, health care provider, or        contact the Automated Inquiry System (AIS) at
   other responsible party faxes a copy of the                 1-800-925-9126.
   “Ambulance Fax Cover Sheet” on page B-6 to the
   TMHP Ambulance Unit at 1-512-514-4205. Infor-               9.3.3.5 Prior Authorization Types, Definitions
   mation and documentation listed on the form must
   be sent with the request before the transport to the        Short Term
   initial or next medical appointment. Documentation          Short-term prior authorizations are issued to a client
   requirements are outlined in this section under             whose condition meets the severely disabled criteria for a
   “Supporting Documentation” on page 9-5.                     short period of time. The length of the prior authorization
                                                               is determined based on the treating physician’s or


9–4
                                                                                                                 Ambulance


surgeon’s prognosis of recovery. If a recovery period          9.3.4 Claim Denials and Appeals
cannot be determined at the time the prior authorization
                                                               Ambulance claims submitted without the PAN are denied
is requested, the TMHP Ambulance Unit defaults the
                                                               and must be appealed on paper by the provider. The
authorization to 60 days with the option for an extension
                                                               appeal must be accompanied by supporting documen-
based on updated documentation received before the
                                                               tation. Clients may appeal PAN request denials by
60 days have lapsed. Hospital-to-hospital and hospital-to-
                                                               contacting TMHP Client Notification at 1-800-414-3406.
outpatient medical facility transports are issued a PAN for
that transport only. If the client already has a short-term    Important: All ambulance denials (air or ground) must be
or annual PAN, the PAN may be used for the ambulance           appealed on paper. Telephone and electronic appeals are
transport. The hospital is responsible for obtaining the       not accepted.
prior authorization.                                           For claims or appeals related to prior authorization denials
Annual                                                         for the 180-day authorization request, the Physician Certi-
Annual prior authorizations are issued to a client who         fication Form is not considered as documentation after
meets the severely disabled criteria and whose condition       the service is rendered.
is not expected to improve within the year. These authori-     On appeal, supporting documentation is critical for deter-
zations are valid for a 12-month period as long as all other   mining the client’s condition. Ambulance providers who
eligibility criteria are met.                                  file paper claims must include all information that
180-Day                                                        supports the reason for the transport and attach a copy of
                                                               the run sheet to the claim. The emergency medical
180-day prior authorizations are issued to a client and are    technician (EMT) who transported the client must sign the
granted within 24 hours from the time received, excluding      documentation.
weekends and holidays for authorization of nonemergency
ambulance services. The request must be effective for a        Refer to: “Supporting Documentation” on page 9-5.
period of 180 days from the date of issuance if the
request includes a written statement from a physician.
Requests can be submitted up to 60 days before the date        9.3.5 Ambulance Disposable Supplies
of service. The provider requesting this authorization is      Reimbursement for disposable supplies is separate from
required to complete the certification form on page B-70       the established global fee for ambulance transports.
in its entirety. Incomplete forms are not considered as a      Providers should use one procedure code, 9-A0382, to
valid authorization request and are returned with a denial     combine all payable disposable supplies used (for              9
letter. The Physician Certification form is not considered     example, gauze, bandages, tape, suction catheter,
documentation after the service is rendered and should         gloves, and mask) during emergency and nonemergency
not be sent with a claim or an appeal.                         ambulance transports. Reimbursement for this procedure
                                                               code is limited to a maximum of $20.30 per transport
                                                               (one-way) and $40.60 round trip. A maximum of
9.3.3.6 Supporting Documentation
                                                               two-supply procedure codes are allowed per round trip. In
Providers must submit supporting documentation                 situations involving multiple transports on the same date
(examples follow) with all prior authorization requests.       of service, the provider may appeal claims denied
• Admit and discharge records with prognosis, including        because they exceed two-supply procedure codes per
  emergency room records                                       claim. When billing for nonpayable supplies, providers
                                                               must bill the appropriate national code. Providers must
• A history and physical completed within six months or a
                                                               provide medically necessary supplies for the client’s safe
  care plan detailing daily activities from a facility or
                                                               transport.
  home health agency
• A letter on the health care provider’s letterhead
  including the patient’s primary mode of mobility and         9.3.6 Oxygen
  diagnosis history                                            Reimbursement for oxygen is the lesser of the provider's
In hospital-to-hospital transports or hospital-to-outpatient   customary profile, the prevailing profile, or the provider's
medical facility transports, the Ambulance Unit considers      actual charge in accordance with 1 TAC §355.8600. A
information by telephone from the hospital. Beginning          maximum of two oxygen procedure codes are allowed per
June 1, 2005, providers are no longer required to fax          round trip. In situations involving multiple transports on
medical documentation to TMHP; however, in certain             the same date of service, the provider may appeal claims
circumstances, TMHP may request the hospital fax the           that have denied for this two-code limit. Provider's must
supporting documentation.                                      bill the appropriate national code.


                                                               9.3.7 Waiting Time
                                                               Procedure code 9-A0420, may be billed when it is the
                                                               general billing practice of local ambulance companies to
                                                               charge for unusual waiting time (longer than 30 minutes).
                                                               Providers must use the following procedures:


                                                                                                                        9–5
Section 9


• Separate charges must be billed for all clients,           9.5.2 Out-of-Locality Transports
  Medicaid and non-Medicaid, for unusual waiting time.
                                                             Transports to out-of-locality providers are covered if a local
• The circumstances requiring waiting time and the exact     facility is not adequately equipped to treat the condition.
  time involved must be documented in Block 24 of the        Out-of-locality refers to one-way transfers of 50 or more
  CMS-1500 claim form.                                       miles from point of pickup to point of destination.
• The amount charged for waiting time must not exceed        Important: Transports may be cut back to the closest
  the charge for a one-way transfer.                         appropriate facility.
Important: Waiting time is reimbursed up to one hour.
                                                             9.5.3 Air or Boat Transports
9.3.8 Extra Attendant or Registered Nurse                    Air ambulance transport services, by means of either fixed
Charges for an extra attendant or registered nurse (in       or rotary wing aircraft, may be covered only if one of the
addition to the two-person crew) for an ambulance transfer   following conditions exists:
are reimbursed when the claim documents the medical          • The client’s medical condition requires immediate and
necessity of advanced life-support services (for example,      rapid ambulance transportation that could not have
procedure code 9-A0424). Without documentation of the          been provided by ground ambulance.
medical need of the third attendant, the third attendant’s
                                                             • The point of client pick-up is inaccessible by ground
services are not reimbursable. Medicaid does not
                                                               vehicle.
reimburse based on each ambulance provider’s internal
policy.                                                      • Great distances or other obstacles are involved in
                                                               transporting the client to the nearest appropriate
                                                               facility.
9.3.9 Night Call                                             Important: Air transport claims may be submitted on
The Medicaid program does not reimburse an extra charge      paper with supporting documentation. Claims may be
for a night call.                                            submitted electronically with a short description of the
                                                             client’s physical condition in the comment field. If the
                                                             client’s condition cannot be documented, providers must
9.4 Membership Fees                                          file a paper claim.

The Texas Insurance Code does not apply to ambulance
providers who finance, in part or in whole, the ambulance    9.5.4 Pregnancy Transports
service by subscription. HHSC’s Bureau of Emergency
                                                             Transporting a pregnant woman may be covered as an
Management and Bureau of Policy and Operations have
                                                             emergency transfer if the client’s condition is documented
specific guidelines about these subscription plans. For
                                                             as an emergency situation at the time of transfer.
more information, providers may contact their regional
EMS program administrator or the HHSC Emergency              Claims documenting a home delivery or delivery en route
Medical Services Division at 1-512-834-6700.                 are considered emergency transfers. Premature labor and
                                                             early onset of delivery (less than 37 weeks gestation) also
                                                             may be considered an emergency. Active labor without
9.5 Types of Transport                                       more documentation of an emergency situation is not
                                                             payable as an emergency transport.
                                                             Important: First day of last menstrual period (LMP) or
9.5.1 Multiple Client Transports                             estimated due date (EDD) must be in Block 14 of the
Multiple client transports occur when more than one client   claim form and on the documentation.
with Medicaid coverage is transported in the same vehicle    If the pregnant client is transported in an ambulance on a
simultaneously. A claim for each client must be completed    nonemergency basis, all criteria for nonemergency prior
and must reference multiple transfers with the names and     authorization must be met.
Medicaid numbers of other clients sharing the transfer in
Block 19 of the CMS-1500 claim form. Providers must
enter charges on a separate claim for each client. TMHP      9.5.5 Transports to or From State
adjusts the payment to 80 percent of the allowable base      Institutions
rate for each claim and divides mileage equally among the
                                                             Ambulance transports to or from a state-funded hospital
clients who share the ambulance.
                                                             for admission or following discharge are covered when
Important: Mileage determinations are based on the           nonemergency transfer criteria are met. Ambulance
Official State Mileage Guide.                                transfers of clients while they are inpatients of the insti-
Refer to: “Claims Filing Instructions” on page 5-17.         tution are not covered. The institution is responsible for
                                                             routine nonemergency transportation.




9–6
                                                                                                                   Ambulance


9.5.6 Transports for Nursing Facility                            result in a transport, the provider should have the client
Residents                                                        sign an acknowledgment statement and bill the client for
                                                                 services rendered.
Transports from a nursing facility to a hospital are covered
if the client’s condition meets emergency criteria.
Nonemergency transfers for the purpose of required
diagnostic or treatment procedures not available in the          9.6 Medicare/Medicaid Coverage
nursing facility (such as dialysis treatments at a               Medicaid is the secondary payor to other health insurance
freestanding facility) are also allowable only for clients       sources including Medicare. Ambulance claims for
meeting the definition of severely disabled. Transports of       Medicaid and Medicare Part B claims must be filed with
nursing facility residents for rehabilitative treatment (for     Medicare first.
example, physical therapy) to outpatient departments or
                                                                 MQMBs are eligible for Medicaid benefits such as
physicians’ offices for recertification examinations for
                                                                 ambulance transports. Qualified Medicare Beneficiaries
nursing facility care are not reimbursable ambulance
                                                                 (QMBs) are not eligible for Medicaid benefits. The
services. The nursing facility is responsible for providing
                                                                 Medicaid program is only required to pay for coinsurance
routine nonemergency transportation for services not
                                                                 and/or deductible for QMBs. Therefore, providers should
provided in the nursing facility. The cost of such transpor-
                                                                 not request prior authorization for ambulance services for
tation is included in the nursing facility vendor rate. Claims
                                                                 these clients.
for services to nursing facility residents must indicate the
medical diagnosis or problem requiring treatment, the            Important: Providers must use national procedure codes
medical necessity for use of an ambulance for the                when billing Medicaid.
transport, and the type of treatment rendered at the desti-      Refer to: “Medicare/Medicaid Clients” on page 4-11.
nation (for example, admission or X-ray).
If a client is returned by ambulance to a nursing facility
following hospitalization, the acute condition requiring         9.6.1 Medicare Paid
hospitalization must be noted on the ambulance claim             Assigned claims filed with and paid by Medicare are
form. This transport is only considered for payment if the       automatically transferred to TMHP for payment of the
client meets the severely disabled criteria.                     deductible and coinsurance liability.
Nursing facilities are responsible for providing or arranging    Providers must submit Medicare-paid claims that do not
transportation for their residents. Arranging transportation     cross over to TMHP for the coinsurance and deductible.         9
for Medicaid clients includes obtaining prior authoriza-         Providers must send the Medicare Remittance Advice (RA)
tions for nonemergency ambulance transports.                     with the client information circled in black ink.
Ambulance providers may assist nursing facilities in
obtaining prior authorizations.
Ambulance providers may only bill a nursing facility or          9.6.2 Medicare Denied
client for a nonemergency ambulance transport under the          All claims denied by Medicare for administrative reasons
following circumstances:                                         must be appealed to Medicare before sending to
• Providers are to bill the nursing facility when the nursing    Medicaid.
  facility requests the nonemergency ambulance                   An assigned claim denied by Medicare because the client
  transport without a prior authorization number.                has no Part B benefits, or because the transport desti-
• Providers are to bill the client only when the client          nation is not allowed, can be submitted to TMHP for
  requests transport that is not an emergency, and the           consideration.
  client does not meet the severely disabled criteria. The       Providers must send claims to TMHP on a CMS-1500 with
  provider must advise the client of acceptance as a             the ambulance TPI, unless they are a hospital-based
  private pay patient at the time the service is provided,       provider. If so, providers must file the claim on a HCFA-
  and the client is responsible for payment of all services.     1450 (UB-92) with the hospital TPI.
  Providers are encouraged to have the client sign the           Note: All claims for STAR+PLUS clients with Medicare and
  Private Pay Agreement.                                         Medicaid should follow the same requirements noted in
Providers may refer questions about a nursing facility’s         “Prior Authorization” on page 9-2, including obtaining prior
responsibility for payment of a transport to the TMHP            authorization for Medicaid-only services from TMHP. The
Ambulance Unit at 1-800-925-9126 or TMHP provider                STAR+PLUS HMO is not responsible for reimbursement of
relations representatives.                                       these services.


9.5.7 No-Transport                                               9.7 Relation of Service to Time of
The Medicaid program does not reimburse providers for            Death
services that do not result in a transport to a facility,
regardless of any medical care rendered. If a client             Medicaid benefits cease at the time of the client’s death.
contacts an ambulance provider, but the call does not            However, if the client dies in the ambulance while en route
                                                                 to the destination, Medicaid covers the transport. If a


                                                                                                                          9–7
Section 9


physician pronounces the client dead after the ambulance             Nonemergency                                       Maximum
is called, Medicaid covers the ambulance service (base               Code         Limitations                                Fee
rate plus mileage) to the point of pickup. Providers must
                                                                     9-A0425            A0425 is denied if it is                    *
Indicate the date and time the client died in Block nine of
                                                                                        billed without A0428
the CMS-1500 claim form. If a physician or coroner
pronounces the client dead before the ambulance is                   9-A0428                                                        *
called, the service is not covered.                                  9-A0430                                                        *
Important: Equipment and supplies are included in the                9-A0431                                                        *
base rate. They are not separately reimburseable, but are
considered part of another procedure. Therefore,                     9-A0435                                                        *
equipment and supplies cannot be billed to the client.               9-A0436                                                        *
                                                                     *Reimbursed at reasonable charge, which is the lesser of
                                                                     the provider’s customary profile, the prevailing profile, or
9.8 Ambulance Procedure Codes                                        the provider’s actual charge in accordance with 1 TAC
                                                                     §355.8600.
Use the following procedure codes when billing for
ambulance services provided to Medicaid-eligible clients:
 Emergency                                          Maximum         9.9 Claims Information
 Code             Limitations                            Fee
                                                                    Providers must submit ambulance services to TMHP on a
 9-A0382          Maximum allowable fee of             $20.30       CMS-1500 claim form. Providers must purchase
                  $20.30 is per transport,                          CMS-1500 claim forms from a vendor of their choice;
                  not to exceed $40.60                              TMHP does not supply them. Providers may file emergency
                  round trip.                                       and nonemergency ambulance services claims to TMHP in
 9-A0420                                                        *   an approved electronic format. Nonemergency claims filed
                                                                    electronically must include the PAN in the appropriate
 9-A0422                                                        *
                                                                    field.
 9-A0424                                                        *
                                                                    Reminder: Providers must submit multiple transports for
 9-A0425          Use modifier ET to denote                     *   the same client on the same date of service through one
 with modifier    emergency services.                               claim submission.
 ET               A0425-ET is denied if it is
                                                                    Refer to: “Reimbursement” on page 2-2.
                  billed without A0429.
 9-A0429                                                        *
 9-A0430                                           $1,140.08        9.9.1 Modifiers on Ambulance Claims
 9-A0431                                              $609.00       Ambulance providers may see the HH modifier on their
                                                                    Remittance and Status (R&S) reports, which indicates the
 9-A0435                                               $16.24       transfer is from a noncontracted to a contracted hospital.
 9-A0436                                               $16.24       It does not affect claim payment or processing.
 9-A0999          Use for water ambulance                   MP      Modifier TG may be used to indicate ALS services were
                  services.                                         provided when billing BLS procedure codes.
 *Reimbursed at reasonable charge, which is the lesser of
 the provider’s customary profile, the prevailing profile, or
 the provider’s actual charge in accordance with 1 TAC              9.9.2 Claim Filing Resources
 §355.8600.                                                         Providers may refer to the following sections or forms
                                                                    when filing claims:
                                                                                                                         Page
 Nonemergency                                       Maximum
                                                                     Resource                                            Number
 Code         Limitations                                Fee
                                                                     Automated Inquiry System (AIS)                      xi
 9-A0382            Maximum allowable fee              $20.30
                    of $20.30 is per                                 TMHP EDI General Information                        3-1
                    transport, not to exceed                         CMS-1500 Claim Filing Instructions                  5-18
                    $40.60 round trip.
                                                                     Communication Guide                                 A-1
 9-A0420                                                        *
                                                                     Ambulance Claim Example 1                           D-3
 9-A0422                                                        *
                                                                     Ambulance Claim Example 2                           D-4
 9-A0424                                                        *
                                                                     Ambulance Claim Example 3                           D-4
 *Reimbursed at reasonable charge, which is the lesser of
 the provider’s customary profile, the prevailing profile, or        Acronym Dictionary                                  F-1
 the provider’s actual charge in accordance with 1 TAC
 §355.8600.


9–8

				
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