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    v1.0.30
    OpenPayerPolicy UpdatesReimbursement/Payment PolicyWellpoint Transportation Policy Update | OpenPayer
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    CurrentWellpointPolicy G-07036

    Transportation Services: Ambulance and Non-Emergent Transport

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    Washington Medicaid reimbursement for ambulance and non-emergency medical transportation to and from covered or contractually mandated services, including coverage criteria, nonreimbursable services, billing requirements, and transportation modifiers.

    Policy Summary
    PayerWellpoint
    PolicyTransportation Services: Ambulance and Non-Emergent Transport
    Policy CodePolicy G-07036
    Change TypeNo material change
    Effective DateDecember 19, 2023
    Next Review DateN/A
    Key ActionBill ambulance and NEMT transportation claims with origin and destination modifiers; claims without the required modifiers may be denied.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    2Transportation categories
    Nearest facilityDestination standard
    RequiredModifiers
    Base + mileageAmbulance billing
    5

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    NEMT service categories
    Not reimbursableExcluded charges

    Covered and Nonreimbursable Transportation

    Covered transportation reimbursement criteria

    Transportation is reimbursable when it is for a covered or contractually mandated service and all applicable transportation, level-of-care, mode, coding, destination, authorization, and medical-necessity requirements are met.

    ALL of the following

    • Transport is to or from a covered service or another service mandated by contract.
    • Ambulance transport is to the nearest facility equipped to treat the member.
    • The billed service uses the appropriate ambulance level of care or NEMT mode.
    • The claim includes required origin and destination modifiers, unless an identified exception applies.
    • The billed services and supplies are supported by applicable authorization, medical necessity, coding, and medical-record requirements.

    Nonreimbursable transportation criteria

    The following transportation services and circumstances are not reimbursable under the policy.

    ANY of the following

    • Transport is for member or caregiver convenience, a no-show member, or transportation available free of charge.
    • Mileage is unloaded, for additional passengers, or beyond the nearest appropriate facility.
    • The ambulance provides treatment without transport, uses an unnecessarily high level of care, duplicates BLS and ALS billing, or includes services already in the ambulance base rate.
    • The service involves nontransporting responding providers, vehicle maintenance or gas, vendor lodging or meals, or another specifically excluded charge.

    Transportation Coding and Billing Components

    Ambulance origin and destination modifiersModifier
    DDiagnostic or therapeutic site/free-standing facility other than P or H; use as an origin or destination modifier.
    EResidential, domiciliary, or custodial facility; use as an origin or destination modifier.
    GHospital-based dialysis facility; use as an origin or destination modifier.
    HHospital, inpatient or outpatient; use as an origin or destination modifier.
    ISite of transfer between two types of ambulance; use as an origin or destination modifier.
    JNonhospital-based dialysis; use as an origin or destination modifier.
    NSkilled nursing facility, including swing bed; physician's office information is also included in the policy modifier grid.
    PHMO nonhospital facility, clinic, or private residence; use as an origin or destination modifier.
    RPrivate residence; use as an origin or destination modifier.
    SScene of accident or acute event; use as an origin or destination modifier.
    Additional transportation modifiersModifier
    QLMember died after the ambulance was contacted; origin and destination modifiers are not required with this modifier.
    QMProvider arranged transportation services; additional to origin and destination modifiers.
    QNProvider furnished transportation services; additional to origin and destination modifiers.
    TKMultiple carry trips; additional to origin and destination modifiers.
    TQLife support transport by a volunteer ambulance provider; additional to origin and destination modifiers.
    Ambulance destination
    Destination standardTransport must be to the nearest facility equipped to treat the member.
    Mileage ruleMileage beyond the nearest appropriate facility is not reimbursable.
    Applies toAmbulance transportation and associated services and supplies.
    Ambulance level of care
    Reimbursement basisAmbulance reimbursement is based on the ambulance base rate per trip and the appropriate level of care provided to the member.
    Higher level of careA higher level of care is not reimbursable when a lower level is more appropriate.

    Claims Submission and Provider Requirements

    Documentation Required

    Support claims with compliant coding and documentation

    Submit claims using compliant industry-standard CPT, HCPCS, and/or revenue codes. The billed services must be fully supported by the medical record and/or office notes and must meet applicable authorization and medical necessity requirements.

    Billing Rule

    Report origin and destination modifiers

    Bill ambulance and NEMT transportation claims with the required origin and destination modifiers. Claims without the required modifiers may be denied.

    Transportation Terms

    Advanced Life Support (ALS)
    DefinitionAdvanced Life Support (ALS) consists of invasive services.
    PersonnelServices are provided by personnel trained as emergency medical technicians.
    Service typeALS is an ambulance level of care.
    Air ambulance
    DefinitionAn air ambulance is an equipped and staffed aircraft necessary to rapidly transport a member to the nearest appropriate facility.
    Ground transport limitationAir ambulance transport is used when ground ambulance transport could not otherwise be accomplished or accessed without endangering the member’s health.
    Policy Summary
    PayerWellpoint
    PolicyTransportation Services: Ambulance and Non-Emergent Transport
    Policy CodePolicy G-07036
    Change TypeNo material change
    Effective DateDecember 19, 2023
    Next Review DateN/A
    Key ActionBill ambulance and NEMT transportation claims with origin and destination modifiers; claims without the required modifiers may be denied.
    SourceLink
    On This Page
    Covered and Nonreimbursable TransportationTransportation Coding and Billing ComponentsClaims Submission and Provider RequirementsTransportation Terms
    Billing structureMileage is separately reimbursed from the ambulance base rate.
    Billing Rule

    Bill ambulance base rate and mileage correctly

    Bill ambulance services at the appropriate level of care using the ambulance base rate per trip, and report mileage separately. Equipment, supplies, oxygen, IV drugs, and ambulance personnel services are included in the base rate and should not be separately reimbursed.

    Billing Rule

    Bill NEMT by appropriate mode and service component

    For NEMT, bill the appropriate transportation mode and report each applicable reimbursable service component.

    • Medical transport base rate
    • Additional appropriately licensed medical personnel as needed for the member’s health status
    • Mileage
    • Unusual waiting time
    • Parking and/or toll fees
    Denial Risk

    Exclude nonreimbursable transport charges

    Do not bill transportation charges that the policy excludes from reimbursement, including convenience transport, no-show members, free transportation, unloaded mileage, additional passengers, and vendor or vehicle-related expenses.

    • Mileage when the transport service is denied or not covered
    • Additional mileage or attendant rates for additional passengers
    • Transportation vendor or supplier lodging or meals
    • Vehicle maintenance or gas
    • Additional rates for night, weekend, or holiday calls
    Denial Risk

    Avoid ambulance-specific denial conditions

    Avoid ambulance billing situations that are not reimbursable, including treatment without transport, transport when another means can be used without endangering the member’s health, and a higher level of care when a lower level is more appropriate.

    • Do not separately reimburse services or items included in the ambulance base rate.
    • Do not bill both basic and advanced life support when ALS services are provided.
    • Do not bill responding ambulance providers that do not transport the member.
    • Do not bill mileage beyond the nearest appropriate facility.
    Documentation Required

    Follow governing submission requirements

    Follow the provider manual and applicable state, federal, CMS, and contractual requirements for transportation claim submission. Failure to follow proper billing and submission guidelines may result in claim rejection or denial, payment recovery, or reimbursement adjustment.

    Aircraft types
    Air ambulances may be rotary-wing helicopters or fixed-wing commercial or private aircraft.
    Ambulance transportation
    DefinitionAmbulance transportation is medically necessary transport of a member by medically skilled personnel.
    DestinationTransport is to the nearest appropriate facility equipped to provide care for the member’s injury or illness.
    ClassificationsServices are classified as Basic Life Support (BLS) or Advanced Life Support (ALS), and as emergency or non-emergency.
    Basic Life Support (BLS)
    DefinitionBasic Life Support (BLS) consists of noninvasive services.
    PersonnelServices are provided by personnel trained as basic emergency medical technicians.
    RequirementsServices are provided in accordance with applicable state laws.
    Emergency ambulance transportation
    DefinitionEmergency ambulance transportation is an urgent service for a sudden, unexpected onset of acute illness or injury.
    Care requiredThe illness or injury requires immediate medical or surgical care.
    Potential consequenceIf not immediately treated, the condition could result in death or permanent impairment to the member’s health.
    Ground ambulance
    DefinitionA ground ambulance is an equipped and staffed land or water vehicle.
    Transport positionThe vehicle is designed to transport a member in the supine position.
    Vehicle typeGround ambulance includes a land or water vehicle used for member transport.
    Nonemergency ambulance transportation
    DefinitionNonemergency ambulance transportation is a scheduled or unscheduled service.
    In-transit requirementThe member requires attention by EMT-trained personnel while in transit.
    Urgency classificationThe service is classified as nonemergency rather than emergency ambulance transportation.
    Non-Emergency Medical Transport Services (NEMT)
    DefinitionNon-Emergency Medical Transport Services (NEMT) provide transportation for members to receive covered services.
    Included modesModes include ambulette or medi-van, wheelchair van, invalid coach, taxicab, mini-bus, and public transportation.
    Public transportation examplesPublic transportation includes bus or subway service.