Mont. Admin. R. 37.86.2602 - AMBULANCE SERVICES, REQUIREMENTS
(1) These
requirements are in addition to those rule provisions generally applicable to
Medicaid providers.
(2) Ambulance
services must be provided by a licensed ambulance provider.
(3) Coverage of ambulance services is limited
to transportation necessary to obtain medically necessary services from the
nearest appropriate facility.
(4)
Coverage for ambulance services is not available where transportation by a mode
other than the ambulance could be utilized without endangering the patient's
health, whether or not such other transportation is actually
available.
(5) Ground ambulance
service is covered when the patient's medical condition requires transportation
by ambulance. The following are examples of circumstances which may be
considered in determining the medical need for ground ambulance service.
However, the presence or absence of any one or more of the following does not
necessarily establish the medical need for the service:
(a) the patient is transported in an
emergency situation, e.g., as a result of an accident or injury;
(b) the patient is unconscious or in
shock;
(c) the patient requires
oxygen as an emergency rather than a maintenance measure or requires other
emergency treatment on the way to the destination;
(d) the patient has to remain immobile
because of a fracture that has not been set or the possibility of a
fracture;
(e) the patient sustains
an acute stroke or myocardial infarction; or
(f) the patient is hemorrhaging.
(6) Air ambulance services are
covered if:
(a) All coverage requirements for
ground ambulance services as specified in this rule are met; and
(b) One of the following conditions is met:
(i) the point of pickup is inaccessible by
land vehicle; or
(ii) great
distances or other obstacles are involved, and getting the patient to the
nearest hospital with appropriate facilities and emergency admission is
essential, for example, a situation where land transportation is available, but
the time required to transport the recipient by land rather than air would
endanger the recipient's life or health.
(c) Air ambulance services may be covered for
the transfer of a patient from one hospital to another if the transferring
hospital does not have adequate facilities to provide the specialized medical
services needed by the recipient and if the requirements of (6)(a) through
(b)(ii) are met.
(i) Air ambulance services
are not covered to transport a recipient from a hospital capable of treating
the recipient to another hospital simply because the recipient or his family
prefers a specific hospital or physician.
(ii) Mileage is paid only to the nearest
appropriate facility.
(7) Nonemergency scheduled ambulance services
must be prior authorized by the department or its designee.
(8) Medicaid benefits cease at the time of
death. When a recipient is pronounced dead after an ambulance is called but
before pickup, the ambulance service provided to the point of pickup is covered
at the base rate. If a recipient is pronounced dead by a legally authorized
individual before the ambulance is called, no payment will be made.
(9) Emergency ambulance services must be
reported to the department's designee within 180 days of the emergency
transport or within 180 days of the retroactive eligibility determination date,
by submitting an ambulance trip report and the associated professional claim
form.
(10) Prior to processing
payment, the department's designated review organization will evaluate
ambulance claims for emergency services for medical necessity and
appropriateness by reviewing the ambulance trip report and the associated
professional claim form.
(11)
Mileage submitted for travel reimbursement purposes must be rounded to the
nearest whole mile.
(12) Ambulance
services are reimbursable only to the extent that such services are medically
necessary based on the recipient's condition. Where ambulance services are
reimbursable, payment will be based on the level of services provided rather
than being based on the type of vehicle used, regardless of any state or local
ordinances or any policies which contain requirements for ambulance staffing or
furnishing of ambulance services.
Notes
AUTH: 53-6-113, MCA; IMP: 53-6-101, 53-6-113, MCA
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