CMS Pub. 100-02, ch. 10, § 20

Payment may be made for expenses incurred by a patient for ambulance service provided

conditions l, 2, and 3 in the left-hand column have been met. The right-hand column

indicates the documentation needed to establish that the condition has been met.

Conditions Review Action

1. Patient was transported by

an approved supplier of

ambulance services.

1. Ambulance suppliers are explained in greater detail in

§10.1.3

2. The patient was suffering

from an illness or injury,

which contraindicated

transportation by other

means. (§10.2)

2. (a) The A/B MAC (A) or (B) presumes the requirement

was met if the submitted documentation indicates that the

patient:

• Was transported in an emergency situation, e.g., as

a result of an accident, injury or acute illness, or

• Needed to be restrained to prevent injury to the

beneficiary or others; or

• Was unconscious or in shock; or

• Required oxygen or other emergency treatment

during transport to the nearest appropriate facility;

or

• Exhibits signs and symptoms of acute respiratory

distress or cardiac distress such as shortness of

breath or chest pain; or

• Exhibits signs and symptoms that indicate the

possibility of acute stroke; or

• Had to remain immobile because of a fracture that

had not been set or the possibility of a fracture; or

• Was experiencing severe hemorrhage; or

• Could be moved only by stretcher; or

• Was bed-confined before and after the ambulance

trip.

(b)

Conditions Review Action

In the absence of any of the conditions listed in (a) above

additional documentation should be obtained to establish

medical need where the evidence indicates the existence

of the circumstances listed below:

(i) Patient’s condition would not ordinarily require

movement by stretcher, or

(ii) The individual was not admitted as a hospital inpatient

(except in accident cases), or

(iii) The ambulance was used solely because other means

of transportation were unavailable, or

(iv) The individual merely needed assistance in getting

from his room or home to a vehicle.

(c) Where the information indicates a situation not listed

in 2(a) or 2(b) above, refer the case to your supervisor.

3. The patient was

transported from and to

points listed below.

(a) From patient’s residence

(or other place where need

arose) to hospital or skilled

nursing facility.

3. Claims should show the ZIP Code of the point of

pickup.

(a)

i. Condition met if trip began within the institution’s

service area as shown in the A/B MAC (B)’s locality

guide.

ii. Condition met where the trip began outside the

institution’s service area if the institution was the nearest

one with appropriate facilities.

NOTE: A patient’s residence is the place where he or she makes his/her home and dwells

permanently, or for an extended period of time. A skilled nursing facility is one, which is

listed in the Directory of Medical Facilities as a participating SNF or as an institution

which meets §1861(j)(1) of the Act.

NOTE: A claim for ambulance service to a participating hospital or skilled nursing facility

should not be denied on the grounds that there is a nearer nonparticipating institution

having appropriate facilities.

(b) Skilled nursing facility to

a hospital or hospital to a

skilled nursing facility.

(b)

(i) Condition met if the ZIP Code of the pickup point is

within the service area of the destination as shown in the

A/B MAC (B)’s locality guide.

(ii) Condition met where the ZIP Code of the pickup point

is outside the service area of the destination if the

destination institution was the nearest appropriate facility.

Conditions Review Action

(c) Hospital to hospital or

skilled nursing facility to

skilled nursing facility.

(c) Condition met if the discharging institution was not an

appropriate facility and the admitting institution was the

nearest appropriate facility.

(d) From a hospital or skilled

nursing facility to patient’s

residence.

(d)

(i) Condition met if patient’s residence is within the

institution’s service area as shown in the A/B MAC (B)’s

locality guide.

(ii) Condition met where the patient’s residence is outside

the institution’s service area if the institution was the

nearest appropriate facility.

(e) Round trip for hospital or

participating skilled nursing

facility inpatients to the

nearest hospital or

nonhospital treatment

facility.

(e) Condition met if the reasonable and necessary

diagnostic or therapeutic service required by patient’s

condition is not available at the institution where the

beneficiary is an inpatient.

NOTE: Ambulance service to a physician’s office or a physician-directed clinic is not

covered. See §10.3.8 above, where a stop is made at a physician’s office en route to a

hospital and §10.3.3 for additional exceptions.)

4. Ambulance services

involving hospital admissions

in Canada or Mexico are

covered (Medicare Claims

Processing Manual, Chapter 1,

“General Billing

Requirements, Ҥ10.1.3.) if the

following conditions are met:

4. (a) The foreign hospitalization has been determined to

be covered; and

(b) The ambulance service meets the coverage

requirements set forth in §§10-10.3. If the foreign

hospitalization has been determined to be covered on the

basis of emergency services (See the Medicare Claims

Processing Manual, Chapter 1, “General Billing

Requirements,” §10.1.3), the necessity requirement

(§10.2) and the destination requirement (§10.3) are

considered met.

5. The A/B MAC (B) will

make partial payment for

otherwise covered ambulance

service, which exceeded limits

defined in item 6. The A/B

MAC (B) will base the

payment on the amount

payable had the patient been

transported:

5 & 6 (a) From the pickup point to the nearest

appropriate facility, or

5 & 6 (b) From the nearest appropriate facility to the

beneficiary’s residence where he or she is being returned

home from a distant institution.