Information Regarding Medicare Patients
This information was gathered from the Medicare site at
For an easier breakdown of coverages, click here.
The Certificate of Medical Necessity can be downloaded here .
Covered Ambulance Services
To be covered, ambulance service must be medically necessary and reasonable.
A. Necessity for the Service - Medical necessity is established when the patient's condition is such that use of any other method of transportation is contraindicated.
B. Reasonableness of the Ambulance Trip - An ambulance trip may not be covered on the grounds that the use of an ambulance was unreasonable in the treatment of the illness or injury involved notwithstanding the fact that the patient's condition may have contraindicated the use of other means of transportation.
Indications and Limitations of Coverage
Ambulance service must be medically necessary and reasonable. Medical necessity is established when the patient's clinical condition is such that the use of any other method of transportation, such as taxi, private car, wheelchair coach, or other type of vehicle would be contraindicated (e.g., would endanger the patient's medical condition). In any case, in which some means of transportation other than an ambulance could be utilized without endangering the individual's health, whether or not such other transpiration is actually available, no payment may be made for ambulance service.
The patient's condition at the time of the transport is the determining factor in whether a trip will be covered. The fact that the patient is elderly, has a positive medical history, or cannot care for him/herself does not establish medical necessity. Claims may be denied if the use of the ambulance service is unreasonable for the illness or injury involved.
Medicare will not pay for ambulance service when an ambulance was used simply for convenience or because other means of transportation were not available.
Reimbursement may be made for expenses incurred by a patient for ambulance services that meet the following conditions:
1. Was transported in an emergency situation, e.g., as a result of an accident, injury or acute illness, or
2. Needed to be restrained, or
3. Was unconscious or in shock, or
4. Required oxygen or other emergency treatment on the way to his destination, or
5. Had to remain immobile because of a fracture that had not been set or the possibility of a fracture, or
6. Sustained an acute stroke or myocardial infarction, or
7. Was experiencing severe hemorrhage, or
8. Was bed confined before and after the ambulance trip (see note below), or
9. Could be moved only by stretcher
NOTE: The Health Care Financing Administration has defined "bed confinement" as (all three bullets must be met):
The patient is:
- unable to get up from bed without assistance;
- unable to ambulate; and
- unable to sit in a chair or wheelchair.
As defined, the term "bed confined" is not synonymous with "bed rest" or "non-ambulatory." In addition, "bed confined" is not meant to be the sole criterion to be used in determining medical necessity. It is one factor to be considered when making medical necessity determinations.
Physician Certification (CMN)
Effective for services provided on or after September 9, 1999 , Medicare will require ambulance providers to obtain a physician's written order certifying the need for an ambulance, for scheduled and unscheduled nonemergency transports. In addition to the physician's signature, it is acceptable to obtain signed certification statements when professional services are furnished by physician assistants, nurse practitioners, or clinical nurse specialist (where all applicable State licensure or certification requirements are met).
The physician's certification must be dated no more than 60 days prior to the date that the service is provided. In cases where a beneficiary requires a nonemergency, unscheduled transport, the physician's certification can be obtained 48 hours after the ambulance transportation has been provided.
In addition to obtaining the certification, ambulance suppliers are required to retain the certificate on file and, upon request, present the requested certification. This requirement applies to both repetitive and one-time ambulance transports. However, there is one exception to the physician certification rule. A physician's certification is not required for nonemergency, unscheduled transportation of beneficiaries residing at home or in facilities where they are not under the direct care of a physician. These situations should be rare because most transports occur for beneficiaries receiving dialysis or diagnostic tests.
For an ambulance trip to be covered, the patient must be transported to the closest participating hospital which has appropriate facilities for treatment. The term "appropriate facilities" means that the institution is generally equipped to provide the needed hospital or skilled nursing care for the illness or injury involved. In the case of a hospital, it also means that a physician or a physician specialist is available to provide the necessary care required to treat the patient's condition. However, the fact that a particular physician does or does not have staff privileges in a hospital is not a consideration in determining whether the hospital has appropriate facilities. Thus, ambulance service to a more distant hospital solely to avail a patient of the service of a specific physician or physician specialist does not make the hospital in which the physician has staff privileges the nearest hospital with appropriate facilities.
The fact that a more distant institution is better equipped, either qualitatively or quantitatively, to care for the patient does not warrant a finding that a closer institution does not have "appropriate facilities". However, a legal impediment barring a patient's admission would permit a finding that the institution did not have "appropriate facilities". An institution is also not considered an appropriate facility if there is no bed available.
A claim for ambulance services to a participating hospital or skilled nursing facility should not be denied on the grounds that there is a nearer non-participating institution having appropriate facilities.
In exceptional situations where ambulance transportation originates beyond the locality of the institution to which the patient was transported (A0360-A0422), full payment may be made for the services only if the evidence clearly establishes that the institution is the nearest one with appropriate facilities. Partial reimbursement may be made for otherwise covered ambulance services which exceed the limits defined above. Such payment should be based on the amount that would have been payable had the patient been transported: (1) from the pickup point to the nearest appropriate facility; or (2) from the nearest appropriate facility to his residence where he is being returned from a distant institution.
Ambulance service to a physician's office or a physician-directed clinic is not covered, unless an emergency stop is made at a physician's office enroute to a hospital or a hospital or skilled nursing facility inpatient is provided round trip transportation for specialized services.
Disposable supplies such as gauze and dressings used in the care of the patient which are utilized in excess of the customary supply may be reimbursed in addition to the ambulance trip.
Payment may be made for night services, waiting time, and the use of extra attendants to handle disturbed patients, and also where the facts indicate that a situation exists beyond normal ambulance transportation. These payment determinations may only be made on a case-by-case basis by the carrier's medical staff.
Certain circumstances dictate when an ambulance trip is paid as a patient transport under Medicare Part A as opposed to an ambulance service under Medicare Part B. The movement of a beneficiary from his or her home, an accident scene, or any other point of origin 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 is covered, assuming medical necessity and other coverage criteria are met, only under Part B as an ambulance service. Part A coverage is not available because, at the time the beneficiary is being transported, he or she is not an inpatient of any provider paid under Part A of the program. The transfer of a beneficiary from one provider to another is also not covered as a Part A provider service because, at the time that the beneficiary is in transit, he or she is not an inpatient of either provider. This service may be covered under Part B.
Once a beneficiary is admitted to a hospital, CAH, or SNF, it may be necessary to transport the patient to another hospital or other site for specialized care. This movement of the patient is considered "patient transportation" and is covered as an inpatient hospital or CAH service under Part A and as a SNF service when the SNF is furnishing it as a covered SNF service and Part A payment is made for that service. 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. Suppliers should verify that Part A payment is not applicable before a Part B claim is submitted.
Vehicle and Crew Requirements
Any vehicle used as an ambulance must be designed and equipped to respond to medical emergencies and, in nonemergency situations, be capable of transporting beneficiaries with acute medical conditions. The vehicle must comply with state or local laws governing the licensing and certification of an emergency medical transportation vehicle. At a minimum, the ambulance must contain a stretcher, linens, emergency medical supplies, oxygen equipment, and other lifesaving emergency medical equipment and be equipped with emergency warning lights, sirens, and telecommunications equipment as required by State or local law. This should include, at a minimum, one two-way voice radio or wireless telephone.
Basic Life Support Ambulances (BLS )
A basic life support (BLS) ambulance is one that provides transportation plus the equipment and staff needed for such basic services as controlling bleeding, splinting fractures, treatment for shock, delivery of babies, and cardio-pulmonary resuscitation (CPR).
Basic Life Support ambulances must be staffed by at least two people, one of whom must be certified as an emergency medical technician (EMT) by the State or local authority where the services are being furnished and be legally authorized to operate all lifesaving and life-sustaining equipment on board the vehicle.
Advanced Life Support Ambulances (ALS)
The ALS vehicle must have specialized life sustaining equipment and specialized staff. Typical of this type of ambulance are mobile coronary care units staffed by personnel trained and authorized to administer intravenous therapy (IVs), provide anti-shock trousers, establish and maintain a patient's airway, defibrillate the heart, provide EKG monitoring, and perform other advanced life support procedures or services.
Advanced Life Support (ALS) vehicles must be staffed by two people with one of the two staff members certified as a paramedic or an EMT who is trained and certified, by the State or local authority where the services are being furnished, to perform one or more ALS service.
Reasons for Noncoverage
No payment may be made for reusable devices and equipment such as backboards, neckboards, inflatable splints, or linens (disposable or not). Such items and services are considered a part of the charge for the ambulance trip. Payment for the ambulance trip includes payment for these items and services.
Advanced life support (ALS) ambulance services are not separately reimbursed if the ALS vehicle does not transport the patient and does not have a contractual arrangement with a BLS entity.
Based upon the state licensure requirements for an ambulance vehicle and crew members, cardiac monitoring is considered an ALS specialized service. Therefore, it is not recognized as a service performed in conjunction with a BLS transport.
Ambulance services provided when other means of transportation could be utilized without endangering the individual's health, whether or not other transportation is actually available.
The service fails to meet the reasonableness requirement even if it meets the medical necessity requirement (e.g., patients receiving diagnostic and/or therapeutic services which could have been reasonably brought to the beneficiary's bedside at less cost than transporting the beneficiary for the services).
Ambulance services for patient or family convenience.
Ambulance suppliers are required to retain documentation on file supporting all ambulance services billed to Medicare (i.e., trip sheets).
Effective for dates of service September 9, 1999 and after, ambulance suppliers are required to obtain/retain a copy of the Certificate of Medical Necessity (CMN) form for all scheduled and unscheduled nonemergency ambulance transports. Paper billers must attach a copy of the CMN to their claim form. Electronic billers must obtain/retain a copy of the CMN form, however, the form should not be sent to Medicare. All pertinent CMN information must be included on electronic claims submissions (see Medicare Special Notice, August 9, 1999 for complete instructions).