CurrentSouth Dakota Department of Social ServicesPolicy N/A

Air Ambulance Services

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This policy governs South Dakota Medicaid coverage, medical necessity, provider eligibility, billing, documentation, and reimbursement for emergency air ambulance transportation by helicopter or fixed-wing aircraft. It applies to participating ambulance providers and eligible Medicaid recipients.

Policy Summary

PayerSouth Dakota Department of Social Services

PolicyAir Ambulance Services

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionMaintain a copy of the licensed practitioner's written order specifying medical necessity and the medically required level of air transportation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30–60+ minGround transport guideline

Nearest appropriateRequired destination

6 yearsRecord retention

6 monthsTimely filing

Loaded miles

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CurrentSouth Dakota Department of Social ServicesPolicy N/A

Air Ambulance Services

Customize your policy alerts

Sign up for all South Dakota Department of Social Services policy alerts

Know when South Dakota Department of Social Services releases new policies or updates existing guidance.

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Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerSouth Dakota Department of Social Services

PolicyAir Ambulance Services

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionMaintain a copy of the licensed practitioner's written order specifying medical necessity and the medically required level of air transportation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

30–60+ minGround transport guideline

Nearest appropriateRequired destination

6 yearsRecord retention

6 monthsTimely filing

Loaded miles

Air Ambulance Coverage Criteria

General Coverage Principles

Covered services must meet all general coverage principles.

General coverage requirements

The provider must be properly enrolled.
The service must be medically necessary.
The recipient must be eligible.

Air Ambulance Coverage

Air ambulance transportation is covered when all of the following criteria are met.

Air ambulance coverage criteria

Transportation is medically necessary because of time, distance, emergency, or other factors, or transportation by another means is contraindicated.
The recipient's medical condition requires immediate and rapid ambulance transportation that could not have been provided by ground ambulance.
A physician or other licensed practitioner has ordered the transportation in writing and specified the required level of air transportation for medical purposes.
The air ambulance is licensed and equipped according to ARSD Ch. 44:05:05.
The recipient is transported to the nearest appropriate facility equipped or trained to provide the necessary service.

Medical Necessity

Medical necessity is established when the time or instability of ground transport threatens survival or seriously endangers health.

Medical necessity

The time needed to transport the recipient by ground, or the instability of ground transportation, threatens the recipient's survival or seriously endangers the recipient's health.
The recipient requires immediate and rapid transport.

Examples of potentially justified conditions

Intracranial bleeding requiring neurosurgical intervention.
Cardiogenic shock.
Burns requiring treatment in a burn center.

Hospital to Hospital Transport

Hospital-to-hospital air transport is covered only when all transfer criteria are met.

Hospital transfer criteria

Transportation by ground ambulance would endanger the recipient's health.
The transferring hospital does not have adequate facilities to provide the medical services needed by the recipient.
Examples of specialized services may include burn care, cardiac care, trauma care, and critical care.
The receiving hospital is the nearest hospital with appropriate facilities.

Covered Services

The following services are eligible for payment when provided by a participating ambulance provider meeting the policy criteria.

Covered service components

Base fee for fixed-wing emergency air ambulance, including one attendant.
Base fee for helicopter emergency air ambulance, including one attendant.
Services of additional attendants when medically necessary.
Transportation of an additional South Dakota Medicaid recipient when billed with the TK modifier.
Loaded mileage.
Mileage may not be billed for more than one recipient per trip.

Transport Cancelled Due to Weather or Other Circumstances

Reimbursement depends on whether the recipient was loaded before the flight was cancelled.

Cancelled flight reimbursement

A flight cancelled at any time before the recipient is loaded onboard is not covered.
This includes cancellation before or after takeoff to the point of pickup when the recipient has not been loaded. The cancellation must result from bad weather or another circumstance beyond the pilot's control.
When transport is cancelled after the recipient is loaded onboard, reimbursement may include the air base fee, loaded mileage if applicable, an additional attendant if applicable, and an additional recipient if applicable.
The cancellation must result from bad weather or another circumstance beyond the pilot's control.

Recipient Death

Reimbursement depends on when the recipient's death is pronounced relative to takeoff and loading.

Recipient death scenarios

If death is pronounced before takeoff to the point of pickup and the dispatcher had notice and reasonable time to abort the flight, the service is not covered.
An aircraft that has only taxied or has been cleared for takeoff but has not actually taken off is treated as not having taken off.
If death is pronounced after takeoff to the point of pickup but before the recipient is loaded, the air base rate is reimbursable with no mileage, and the QL modifier must be used.
If death occurs after the recipient is loaded but before or upon arrival at the receiving facility, reimbursement is made as if the recipient had not died.

Airport-to-hospital and hospital-to-airport transportation is excluded from air ambulance charges. These services must be billed by the ground ambulance provider and may not be included in the air ambulance charge.

A provider may not bill for an air ambulance service when the recipient was not transported.

Services not specifically listed as covered in the covered services section are considered non-covered.

Transport from a hospital capable of treating the recipient is not covered when the transfer is based on the recipient's or family's preference for a specific hospital or physician.

A flight cancelled because of bad weather or another circumstance beyond the pilot's control is not covered when cancelled before the recipient is loaded onboard, whether the cancellation occurs before or after takeoff to the pickup point.

Transportation from an airport to a hospital or from a hospital to an airport is not billed by the air ambulance provider. The service must be billed by the ground ambulance provider under ARSD 67:16:25:08.

Only loaded mileage is billable. Mileage when the recipient is not being transported may not be billed; loaded mileage must be reported in nautical miles.

Air ambulance transportation is not medically necessary when the time or instability of ground transportation does not threaten the recipient's survival or seriously endanger the recipient's health. Air transport may be considered when ground transport would take 30–60 minutes or more for a recipient who requires immediate and rapid transport, but the circumstances must establish medical necessity.

Air transport is not medically necessary when a ground ambulance can provide the required immediate transport without endangering the recipient. For hospital-to-hospital transfers, coverage also requires that the transferring hospital lack adequate facilities and that the receiving hospital be the nearest hospital with appropriate facilities.

Billing and Coding Requirements

Multiple Recipient Transport ModifierModifier

TK	Modifier used when billing transportation of an additional South Dakota Medicaid recipient transported simultaneously to the same destination; the second recipient's base fee is reduced by 50 percent.

Multiple Trips ModifierModifier

59	Modifier required on the claim when a recipient requires multiple air ambulance trips within a 24-hour period, along with other appropriate ambulance modifiers.

Recipient Death ModifierModifier

QL	Modifier to use when the aircraft takes off to pick up a recipient who is pronounced dead after takeoff to the point of pickup but before the recipient is loaded; reimbursement is the air base rate with no mileage.

Covered Ambulance Billing ModifierModifier

TK	Modifier used to bill transportation of an additional South Dakota Medicaid recipient.

Applicable ModifiersModifier

TK	Additional South Dakota Medicaid Recipient
59	Distinct or separate services (multiple trips within a 24-hour period)

Air Ambulance Procedure CodesCPTCovered

No codes listed

Ground Transport Time Guideline

Ground transport guideline30–60 minutes or more

Required recipient conditionThe recipient’s medical condition at pickup requires immediate and rapid transport

Coverage considerationAir transportation may be considered necessary when ground transport time endangers the recipient’s life or health

Record Retention

Retention periodAt least 6 years

Retention start point

Provider Documentation and Denial Risks

Documentation Required

Written Order for Air Transportation

Maintain the physician’s or other licensed practitioner’s written order requiring air transportation for medical purposes. The order must specify the medical necessity and the specific level of air transportation required.

Documentation Required

Medical and Financial Records

Keep legible medical and financial records that fully justify and disclose the extent of services provided and billed to South Dakota Medicaid. Retain the records for at least 6 years after the last date a claim was paid or denied.

Provide records on request.
Refer to the Documentation and Record Keeping manual for additional requirements.

Documentation Required

Policy Background

Air ambulance transportation is medically necessary only when the time or instability associated with ground transport threatens the recipient's survival or seriously endangers the recipient's health. The recipient must require immediate and rapid transport that could not have been provided by ground ambulance; examples that may support air transport include intracranial bleeding requiring neurosurgical intervention, cardiogenic shock, severe burns requiring a burn center, conditions requiring hyperbaric oxygen treatment, multiple severe injuries, and life-threatening trauma.

Policy Definitions

Pronouncement of Death

DefinitionA pronouncement of death is effective for this policy only when made by an individual authorized under state law to make such pronouncements

Authorized individualThe person making the pronouncement must be authorized under state law

Policy applicationAn unauthorized pronouncement does not establish the effective time of death for this policy

Loaded Mileage

DefinitionMileage associated with an air ambulance trip

Billing limitMileage may be billed for no more than one recipient per trip

Loaded mileage measurement

Policy Summary

PayerSouth Dakota Department of Social Services

PolicyAir Ambulance Services

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionMaintain a copy of the licensed practitioner's written order specifying medical necessity and the medically required level of air transportation.

SourceLink

On This Page

A condition requiring treatment in a Hyperbaric Oxygen Unit.

Multiple severe injuries.

Life-threatening trauma.

After the last date a claim was paid or denied

Records coveredLegible medical and financial records that justify and disclose the extent of services provided and billed

Timely Filing

Claim deadlineWithin 6 months following the month the service was provided

Required submissionSouth Dakota Medicaid must receive the completed claim form

Possible exceptionThe time limit may be waived or extended by South Dakota Medicaid in certain circumstances

Reconsideration Filing

Standard filing periodWithin the timely filing period

Alternative reconsideration deadlineWithin 3 months of the date the claim was denied

Possible exceptionThe time limit may be waived or extended by South Dakota Medicaid in certain circumstances

Provider Enrollment Documentation

Ensure all eligible servicing and billing providers’ National Provider Identifiers are enrolled with South Dakota Medicaid. Locum tenens servicing providers must also enroll and be listed on the claim.

South Dakota air ambulances must be licensed and equipped under ARSD Ch. 44:05:05.
Out-of-state providers must be licensed and enrolled with their home state’s Medicaid agency.

Billing Rule

Timely Filing

Submit completed claims within 6 months following the month the service was provided. Submit reconsideration requests within the timely filing period or within 3 months after the claim denial, unless South Dakota Medicaid waives or extends the deadline.

Documentation Required

Written Medical Necessity Order

Maintain the written medical-necessity order in the provider’s records and make it available upon request. The order must identify the medically required level of air transportation.

Billing Rule

Origin and Destination Addresses

List both the origin address and the destination address on every transportation claim.

Denial Risk

Medical Necessity and Destination Criteria

Air ambulance coverage may be denied when the transport is not medically necessary, ground transport could have safely provided the required service, or the destination is not the nearest appropriate facility. Hospital-to-hospital transport also requires that the transferring hospital lack adequate facilities and that the receiving hospital be the nearest one with appropriate facilities.

A recipient or family preference for a specific hospital or physician does not establish coverage.
Medical necessity requires that ground transport would threaten survival or seriously endanger the recipient’s health.

Denial Risk

Provider, Recipient, or Aircraft Eligibility

Payment may be denied when provider enrollment, recipient eligibility, licensing, or aircraft equipment requirements are not met.

The provider must be properly enrolled.
The recipient must be eligible.
The air ambulance must be licensed and equipped under ARSD Ch. 44:05:05.

Billing Rule

Non-Covered Transport Components

Airport-to-hospital and hospital-to-airport transportation is not included in the air ambulance charge. These segments must be billed by the ground ambulance provider.

A provider may not bill for services when the recipient was not transported.
Services not specifically listed as covered are non-covered.

Billing Rule

Cancellation or Death Before Covered Flight Stage

Apply coverage based on whether the recipient was loaded and whether the aircraft actually took off. A flight cancelled before loading is not covered; after loading, the applicable air base fee and eligible loaded mileage may be reimbursable.

If death is pronounced after takeoff to the pickup point but before loading, bill the air base rate with no mileage and use modifier QL.
If death occurs after loading, bill as if the recipient had not died.
A death-related base fee is not covered when the dispatcher had notice and reasonable time to abort, or when the aircraft only taxied or was cleared for takeoff without actually taking off.

Denial Risk

Post-Payment Rate Limitation

A post-payment review may reduce reimbursement when ground transport would have sufficed or when the recipient could have been treated at a nearer appropriate hospital.

Payment may be limited to the amount payable for ground ambulance transport.
When a nearer appropriate hospital was available, payment may be limited to the rate for transport to that hospital.

Denial Risk

Untimely Claim or Reconsideration

Claims and reconsiderations received after the applicable deadlines may be denied.

Claims are generally due within 6 months following the month of service.
Reconsiderations are generally due within the timely filing period or within 3 months after denial.

Billing Rule

Loaded Nautical Mileage

Bill only mileage for which the recipient was loaded and report air mileage in nautical miles.

Do not bill mileage when the recipient was not transported.
Do not report air mileage using a different unit of measurement.

Billing Rule

Valid Air Ambulance Procedure Codes

An air ambulance claim may contain only air ambulance procedure codes listed on the department’s transportation fee schedule.

Denial Risk

Airport-to-Hospital Transport Billed by Ground Ambulance

Airport-to-hospital transportation must be billed by the ground ambulance provider, not the air ambulance provider, under ARSD 67:16:25:08.

Mileage driven or flown while a patient is being transported

Air Ambulance

Aircraft typeFixed-wing aircraft or helicopter

PurposeDesigned or capable of being quickly modified to provide emergency transportation

LicensureLicensed by the Department of Health under chapter 44:05:05

Air Mile

DefinitionA unit of distance equal to one nautical mile

Distance unitNautical mile

Billing applicationAir ambulance loaded mileage is reported in nautical miles

Ambulance Provider

Eligible entityA company, firm, or individual

In-state requirementLicensed by the Department of Health under article 44:05 to provide ambulance services

Out-of-state requirementProvides ambulance services and is a participating Medicaid provider in the state where it is located

Loaded Mileage

DefinitionMileage driven or flown while a patient is being transported

Billable mileageOnly loaded mileage may be billed

Non-billable mileageMileage when the recipient is not being transported is not billable

Trip

DefinitionThe transporting of a person

Covered origins and destinationsFrom the person’s home to a medical provider, between medical providers, or from a medical provider to the person’s home

Medical provider transferTransportation between medical providers is a trip