Home TG
7.00
Billing Requirements For LDT's Only
Definitions:
A.
Medically Necessary – This
means that the service given is in the best interest of the patient’s
health. For ambulance transports, this
means that transportation could not reasonably be done another way. This is important since Medicare and other
insurance coverage is often based on medical necessity. For most insurance companies, emergencies
that have occurred suddenly and appear to need prompt medical treatment in
order to avoid serious medical consequences are not usually questioned. Non-emergencies, to be medically necessary,
usually require that the patient be bed-confined and unable to be moved by any
means other than a stretcher. A
doctor's order, without supporting documentation, rarely justifies medical
necessity.
B.
Emergency Transport
– Transport of a patient for the sudden onset of acute symptoms for
an unforeseen medical condition which could reasonably be expected to place the
patient’s health in serious jeopardy and which requires unscheduled medical
attention in an emergency room.
C.
Non-Emergency Transport
– A “medical transfer” is a transport for a patient who has an appointment
to be seen for an on-going medical problem.
A non-emergency medical transport can also occur when a patient requires
transport back to his/her residence at the end of a hospitalization.
D.
Covered Service – Each
insurance company decides what service it is going to pay for (or “cover”) in
its policies. To determine which
services are covered by your particular policy, you may need to contact your
insurance company.
E.
Specialized Service –
Medicare requires ambulance providers to report whether “specialized service”
was given or not. “Specialized” service
includes the giving of any treatment or medication such as EKG or starting an
I.V.
Medicare Coverage Guidelines
A.
In order for an ambulance transport to qualify for Medicare
payment, it must meet two criteria:
1.
It must be medically necessary
2.
It must be a covered service.
Definitions of “medically necessary” and “covered service” can be found
in the Definitions section above.
B.
The below chart was developed to provide a quick reference to
determine Medicare coverage for medically necessary ambulance transports. Medicare determines coverage by the origin
(the place where the patient is picked up by the ambulance) and the destination
(the place where the patient is taken by the ambulance). Medicare will determine whether the
transport was medically necessary before deciding coverage. If the transport was not medically
necessary, Medicare will refuse to pay.
If Medicare determines the transport was medically necessary, the
following determines coverage:
This chart is intended to provide a general understanding of Medicare coverage. Should you have questions on a particular
case, please take a moment to review the detailed notes for the type of
transfers being considered or contact our billing department
(903-832-8531).
|
Origin
|
Destination
|
Medicare
Covers
|
|
Hospital
|
Home
or Nursing Home
|
Yes
|
|
Hospital
|
Hospital
|
Only
if medical services not available at 1st can be provided at 2nd
No for
patient/physician convenience
|
When requesting non-emergency ambulance service we will need to know:
A.
Where the patient is located.
B.
The name of the caller and his/her telephone number (including
extension).
C.
The date and time of service being requested.
D.
Patient’s destination (including address, floor, apartment
number). The date and time of the patient’s appointment.
E.
Patient’s name.
F.
Age and sex of the patient.
G.
Patient’s diagnosis.
H.
Patient’s physician.
I.
Any unique requirements for the patient (i.e. oxygen; suction;
I.V.)
J.
Is the patient bed-confined?
If so, what makes him/her bed-confined?
Medicare / Medicaid Requirements for Reimbursement
A.
Emergency from any location to hospital
1.
If medical necessity requirements are met, Medicare will pay
80% of their allowed charge after annual deductible has been met.
2.
Medicaid will pay the state rate for emergency transportation
if Medicaid is the patient’s only insurance.
If Medicaid is supplemental to Medicare and Medicare denies the claim
for lack of medical necessity, Medicaid will deny also.
3.
Insurance will cover according to the provisions in the
patient’s insurance contract. (Policies
that are supplements to Medicare generally will not pay unless Medicare
approves the transport).
B.
Non-emergency hospital discharge to private residence or
nursing home
1.
For Medicare, medical necessity must be established. If medical necessity requirements are met,
Medicare will pay 80% of their allowed charge after the annual deductible has
been met. If medical necessity is not
established, Medicare will likely deny payment as "not deemed medically
necessary". To establish medical
necessity, the patient must be bed confined or unable to sit in a wheelchair
unrestrained.
2.
Medicaid may pay the state rate for non-emergency
transportation if Medicaid is the patient’s only insurance. If Medicaid is supplemental to Medicare and
Medicare denies the claim for lack of medical necessity, Medicaid generally
denies also. However, all
non-emergency Texas Medicaid transports require prior-authorization. Please reference the Texas Medicaid section
of this handbook.
3.
Insurance will cover according to the provisions in the patient’s
contract (policies that are supplements to Medicare generally will not pay if
Medicare denies).
4.
HMO’s generally require prior-authorization for non-emergency
transports. Please call your physician
or HMO for this prior-authorization.
5.
As long as medically necessary, Medicare will pay only to
return a patient to his/her place of residence prior to hospital
admission. If the patient was at home
before admission, but is now going to a nursing home, Medicare will not
pay. Medicaid will pay if medically
necessary (i.e. bed confined, can only be moved by stretcher, requires
restraints, etc).
C.
Non-emergency transfer from home/nursing home to hospital
1.
For Medicare, medical necessity must be established. If
medical necessity requirements are met, Medicare will pay 80% of their allowed
charge after the annual deductible has been met. If medical necessity is not established, Medicare will likely
deny payment as "not deemed medically necessary". To establish medical necessity, the patient
must be bed confined or unable to sit in a wheelchair unrestrained.
2.
Medicaid may pay the state rate for the non-emergency
transportation if Medicaid is the patient’s only insurance. If Medicaid is supplemental to Medicare and
Medicare denies the claim for lack of medical necessity, Medicaid generally
denies also. However, all
non-emergency Texas Medicaid transports require prior-authorization. Please reference the Texas Medicaid section
of this handbook.
3.
Insurance will cover according to the provisions in the
patient’s contract. (Policies that are
supplements to Medicare generally will not pay if Medicare denies).
4.
HMO’s require prior-authorization on non-emergency
transports. Please call your physician
or HMO for this prior-authorization.
D.
Non-emergency out of town transfer (non-emergency)
1.
Medicare will pay for the nearest appropriate facility to care
for the patient.
2.
Medicaid will pay for the nearest appropriate facility to care
for the patient. However, all non-emergency
Texas Medicaid transports require prior-authorization. Please reference the Texas Medicaid section
of this handbook.
3.
Insurance will pay if there are provisions for such in the
patient’s insurance contract.
4.
HMO’s generally require prior-authorization for non-emergency
transports. Please call your physician,
or HMO to obtain this prior-authorization. If the patient wishes, LifeNet will
be happy to discuss coverage with the patient’s insurance carrier in advance of
the transport.
5.
Without a guarantee of payment from the patient’s insurance
carrier, LifeNet requires payment of estimated charges in advance.
E.
For Medicare and Medicaid coverage:
1.
If the patient is to be returned to the hospital after the
procedure/treatment; and was never discharged from the original facility, then
the first hospital will include the transport charge in their bill to be
covered under Medicare Part A.
2.
If the patient was discharged from the original facility
because he/she was to be admitted to second facility for services not available
at the first:
3.
If medical necessity requirements are met, Medicare will pay
80% of their allowed charge after the annual deductible has been met. Medicaid may pay the state for non-emergency
transports if Medicaid is the patient’s only insurance. If Medicaid is supplemental to Medicare and
Medicare denies the claim for lack of medical necessity, Medicaid generally
denies also.
4.
Insurance will pay according to the provisions in the
patient’s contract.
5.
HMO’s generally require prior-authorization for non-emergency
transports. Please call your physician
or HMO to obtain this prior-authorization.
Texas medicaid prior-authorization
A.
Effective January 1, 1998, Texas Medicaid requires that all
non-emergency ambulance transports must be pre-authorized. This was published in the Texas Medicaid
Bulletin #128. A non-emergency
transport for Texas Medicaid is defined as:
1.
A client that meets the severely disabled criteria transported
to a scheduled appointment. A client is considered severely disabled when the
client's physical condition limits mobility and requires the client to be bed
confined at all times, unable to sit unassisted at all times or requires
life-support systems to be monitored.
B.
NHIC, the insurance carrier for the Texas Medicaid program,
will respond to prior-authorization requests within 48 hours of receipt of the
requests.
C.
Documentation of the client's condition that meets the
severely disabled definition must be provided at the time of the request.
D.
It is the responsibility of the sending facility to
obtain the prior authorization number.
This must be provided to LifeNet at the time of transfer. Information and documentation must be sent
with the request before the need for transport to the initial or next
medical appointment.
E.
Examples of supporting documentation for prior-authorization
requests are:
1.
Admit and discharge records with prognosis
2.
A history and physical from the primary care physician or the
care plan with daily activity sheet from the nursing home
3.
A history and physical that has been performed within one year
or a letter from the primary care physician on his letterhead
F.
If a letter is sent requesting prior authorization, it must be
on the physician's letterhead and signed by the physician. The letter must include a detailed
description of the client's physical disability or other information
documenting that the client meets the severely disabled criteria.
G.
In hospital to hospital or hospital to outpatient medical
facility transfers and other situations where documentation is not immediately
available, the ambulance unit of NHIC will consider information over the
telephone.
This Fax Form can be found on page 24 of the Texas Medicaid
Bulletin #128.
If you have any questions, please contact NHIC or LifeNet's
Business Office.