Quick Screen:
When Should Medicare Coverage Be Available for Ambulance Transportation
Coverage Criteria:
- Travel by ambulance must be the only safe means of transportation available. It is not sufficient that alternative transportation cannot be arranged. It is necessary to show that the patient’s health would have been jeopardized had he or she been transported any other way.
- Transportation by ambulance must be:
- From any location to the nearest hospital or skilled nursing facility that can provide the appropriate level of care for the patient’s illness or injury;
- From a hospital or skilled nursing facility to the beneficiary’s home;
- From a hospital to a skilled nursing facility;
- From a skilled nursing facility to a hospital;
- From a hospital to another hospital or from a skilled nursing facility to another skilled nursing facility if the original institution could not provide the appropriate level of care for the patient’s illness or injury;
- Round trip transportation from a skilled nursing facility to another provider for medically necessary care not available in the skilled nursing facility.
- Round trip transportation from a patient’s home or skilled nursing facility to the closest facility that provides renal dialysis for patients living with end-stage renal disease.
- Non-emergency transportation will only be covered if the ambulance supplier obtains a physician’s certification indicating that ambulance transportation is necessary because other means of transportation are medically contraindicated.
- The transportation must be provided by a Medicare-certified provider.
Other Important Points:
- Medicare does not cover wheelchair van transportation.
- Medicare usually does not pay for paramedic intercepts.
- Medicare will not pay for transportation from the patient’s home to the patient’s physician office.
- In a non-emergency situation, if the ambulance provider believes that the transport may be denied coverage by Medicare, the provider must issue an Advance Beneficiary Notice (ABN) to notify the benficiary of his/her potential financial responsibility for the transport. There are three questions to ask when determining if an ABN is required for an ambulance transport. If the answer to all of the following is "yes," an ABN should be issued:
- Is this service a Medicare-covered ambulance benefit? AND
- Will payment for part or all of this service be denied because it is not reasoable and necessary? AND
- Is the patient stabel and the patient non-emergent?
In non-emergency situations it is a good idea to ask whether the transportation will be covered before taking the trip.
Billing Information:
- Most medically reasonable and necessary ambulance transportation is covered by and billed to Medicare Part B. Thus the Medicare payment is subject to Part B deductible and co-insurance.
- If the patient is an inpatient at a hospital or skilled nursing facility (SNF) on the day of the ambulance transportation (not the day of discharge), the transportation may be arranged by and billed to the hospital or SNF.
- If the patient is enrolled in hospice and the ambulance transportation is related to the terminal illness, it should be arranged by and billed to the hospice provider.
Appeal:
Ambulance transportation is frequently inappropriately denied Medicare coverage. If a Medicare beneficiary’s transportation meets the coverage guidelines described above, but were denied Medicare coverage, appeal! Review the Medicare Summary Notice to determine the reason for the denial and follow the directions regarding how to appeal. Send a letter with the appeal request explaining why the transportation was medically necessary. Also, if possible, attach a supportive letter from the beneficiary’s physician. If the transport at issue was non-emergent and the provider did not provide you or your representative with an ABN you may be protected from financial liability if Medicare does not cover the transport.
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