CMS Pub. 100-02, ch. 10, § 10.3.3

Patient Transportation that is Covered Under a Packaged Institutional

Service

(Rev.243; Issued: 04-13-18; Effective: 07-16-18; Implementation: 07-16-18)

Transportation of a beneficiary from his or her home, an accident scene, or any other

point of origin is covered under Part B as an ambulance service only to the nearest

hospital, critical access hospital (CAH), or skilled nursing facility (SNF) that is capable

of furnishing the required level and type of care for the beneficiary's illness or injury and

only if medical necessity and other program coverage criteria are met. An ambulance

transport from a SNF to the nearest supplier of medically necessary services not available

at the SNF where the beneficiary is a resident and not in a covered Part A stay, including

the return trip, is covered under Part B provided that the ambulance transportation was

medically reasonable and necessary and all other coverage requirements are met.

Medicare-covered ambulance services are paid either as separately billed services, in

which case the entity furnishing the ambulance service bills Part B of the program, or as a

packaged service, in which case the entity furnishing the ambulance service must seek

payment from the provider who is responsible for the beneficiary’s care. If either the

origin or the destination of the ambulance transport is the beneficiary’s home, then the

ambulance transport is paid separately by Medicare Part B, and the entity that furnishes

the ambulance transport may bill its A/B MAC (A) or (B) directly. If both the origin and

destination of the ambulance transport are providers, e.g., a hospital, critical access

hospital (CAH), skilled nursing facility (SNF), then responsibility for payment for the

ambulance transport is determined in accordance with the following sequential criteria.

NOTE: These criteria must be applied in sequence as a flow chart and not independently

of one another.

1. Provider Numbers:

If the Medicare-assigned provider numbers of the two providers are different, then the

ambulance service is separately billable to the program. If the provider number of both

providers is the same, then consider criterion 2, “campus”.

2. Campus:

Following criterion 1, if the campuses of the two providers (sharing the same provider

numbers) are the same, then the transport is not separately billable to the program. In this

case the provider is responsible for payment. If the campuses of the two providers are

different, then consider criterion 3, “patient status.” “Campus” means the physical area

immediately adjacent to the provider’s main buildings, other areas and structures that are

not strictly contiguous to the main buildings, but are located within 250 yards of the main

buildings, and any of the other areas determined on an individual case basis by the CMS

regional office to be part of the provider’s campus.

3. Patient Status: Inpatient vs. Outpatient

Following criteria 1 and 2, if the patient is an inpatient at both providers (i.e., inpatient

status both at the origin and at the destination, providers sharing the same provider

number but located on different campuses), then the transport is not separately billable.

In this case the provider is responsible for payment. All other combinations (i.e.,

outpatient-to-inpatient, inpatient-to-outpatient, outpatient-to-outpatient) are separately

billable to the program.

In the case where the point of origin is not a provider, Part A coverage is not available

because, at the time the beneficiary is being transported, the beneficiary is not an

inpatient of any provider paid under Part A of the program and ambulance services are

excluded from the 3-day preadmission payment window.

The transfer, i.e., the discharge of a beneficiary from one provider with a subsequent

admission to another provider, is also payable as a Part B ambulance transport, provided

all program coverage criteria are met, because, at the time that the beneficiary is in

transit, the beneficiary is not a patient of either provider and not subject to either the

inpatient preadmission payment window or outpatient payment packaging requirements.

This includes an outpatient transfer from a remote, off-campus emergency department

(ER) to becoming an inpatient or outpatient at the main campus hospital, even if the ER

is owned and operated by the hospital.

Once a beneficiary is admitted to a hospital, CAH, or SNF, it may be necessary to

transport the beneficiary to another hospital or other site temporarily for specialized care

while the beneficiary maintains inpatient status with the original provider. This

movement of the patient is considered "patient transportation" and is covered as an

inpatient hospital or CAH service and as a SNF service when the SNF is furnishing it as a

covered SNF service and payment is made under Part A for that service. (If the

beneficiary is a resident of a SNF and must be transported by ambulance to receive

dialysis or certain other high-end outpatient hospital services, the ambulance transport

may be separately payable under Part B. Also, if the beneficiary is a SNF resident and not

in a Part A covered stay and must be transported by ambulance to the nearest supplier of

medically necessary services not available at the SNF, the ambulance transport, including

the return trip, may be covered under Part B.) Because the service is covered and payable

as a beneficiary transportation service under Part A, the service cannot be classified and

paid for as an ambulance service under Part B. This includes intra-campus transfers

between different departments of the same hospital, even where the departments are

located in separate buildings. Such intra-campus transfers are not separately payable

under the Part B ambulance benefit. Such costs are accounted for in the same manner as

the costs of such a transfer within a single building.