Ambulance transportation can be covered by Medicare Part B if it meets the following criteria:
- The ambulance transportation must be provided by a Medicare-certified provider.
- The ambulance transportation is medically necessary as the individual’s condition is such that other means of transportation are contraindicated. (The individual does not need to be “bed-confined.”)
- The individual requires both the ambulance transportation itself, and the level of services provided (skilled staff and equipped vehicles).
- Transportation by ambulance must meet certain “origin and destination requirements.” Medicare only covers ambulance transportation to and from the following destinations:
- Hospital
- Critical Access Hospital (CAH)
- Skilled Nursing Facility (SNF)
- The individual’s home (from any of the above institutions)
- Dialysis facility for ESRD patients who require dialysis
- The transport must be to the nearest facility that is able to provide the necessary diagnostic and/or therapeutic services.
- Nonemergency transportation by ambulance generally requires a physician certification that the ambulance transportation is medically necessary in that other means of transportation are contraindicated. This may not be required if the beneficiary is residing at home or in a facility and is not under the direct care of a physician.
- In non-emergencies, the provider may be required to provide advance written notice that Medicare will not cover the transportation if all other requirements are met, but the service is not medically necessary (i.e., other means of transportation are possible). If coverage is denied because the transportation does not meet the origin and destination requirements, advance written notice is not required.
- Paramedic intercept services are generally not covered unless the service is furnished in a “rural area” as defined by Medicare, the paramedic intercept service has a contract with one or more volunteer ambulance services, and the service is medically necessary.
- Medicare does not pay for transportation from the individual’s home to the individual’s physician’s/provider’s office.
- Medicare does not cover wheelchair van transportation.
- If the individual is an inpatient at a hospital or skilled nursing facility on the day of the ambulance transportation, the transportation should be arranged by and billed to the inpatient facility.
- If the patient is enrolled in hospice and the ambulance transportation is related to terminal illness, it should be arranged by and billed to the hospice provider.
Advocacy Tips and Appeal (See, 42 CFR §401.40-41):
Ambulance transportation may be inappropriately denied Medicare coverage. Appeal if the Medicare beneficiary’s transportation meets the coverage guidelines described above.
- Review the individual’s Medicare Summary Notice to determine the reason for the denial and follow the directions regarding how to appeal.
- If possible, include a statement from the patient’s physician and/or other health care providers explaining why the ambulance transportation was medically necessary.
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