(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.