7.1.1 STAR and STAR+PLUS Program Enrollment Prior Authorization Emergency Ambulance Services Medicaid Limitations and Exclusions

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1 Section 7Ambulance Enrollment STAR and STAR+PLUS Program Enrollment Reimbursement Medicaid Limitations and Exclusions Benefits and Limitations Prior Authorization Emergency Ambulance Services Emergency Transport Billing Nonemergency Ambulance Services Nonemergency Ambulance Transports Nonemergency Ambulance Transport Prior Authorization Prior Authorization Process Authorization of Retroactive Eligibility Prior Authorization Types, Definitions Supporting Documentation Claim Denials and Appeals Ambulance Disposable Supplies Waiting Time Extra Attendant or Registered Nurse Night Call Membership Fees Types of Transport Multiple Client Transports Out-of-Locality Transports Air or Boat Transports Pregnancy Transports Transports to or From State Institutions Transports for Nursing Facility Residents Hospice Program Spend Down Medicare/Medicaid Coverage Medicare Paid Medicare Denied Relation of Service to Time of Death Ambulance Procedure Codes Claims Information Modifiers on Ambulance Claims Claim Filing Resources

2 Section Enrollment To enroll in the Texas Medicaid Program, ambulance providers must operate according to the laws, regulations, and guidelines governing ambulance services under Medicare Part B; equip and operate under the appropriate rules, licensing, and regulations of the state in which they operate; acquire a license from the Texas Department of State Health Services (DSHS), approving equipment and training levels of the crew; and enroll in Medicare. A hospital-operated ambulance provider must be enrolled as an ambulance provider and submit claims using the ambulance Texas Provider Identifier (TPI), not the hospital TPI (see Medicare/Medicaid Coverage on page 7-7). Reminder: When ambulance providers enroll in Medicaid, they accept Medicaid payment as payment in full. They cannot bill clients for Texas Medicaid-covered benefits. Refer to: Provider Responsibilities on page 2-4 for more information about enrollment procedures STAR and STAR+PLUS Program Enrollment Certain providers may be required to enroll with each STAR and STAR+PLUS health plan to be reimbursed for services provided to STAR and STAR+PLUS members. Contact the individual health plan for enrollment information. Note: Services for STAR+PLUS Program Medicaid Qualified Medicare Beneficiaries (MQMBs) must be prior authorized and processed by TMHP. 7.2 Reimbursement Ambulance services are reimbursed according to a reasonable charge payment methodology in accordance with 1 TAC Ambulance providers are reimbursed for the transport plus mileage. Refer to: Reimbursement Methodology on page 3-2 for more information about reimbursement methodologies Medicaid Limitations and Exclusions Refer to: Medicaid Program Limitations and Exclusions on page 2-12 for information on Medicaid exclusions. 7.3 Benefits and Limitations Medicaid reimburses for emergency and nonemergency (for the severely disabled) transports. For ground transportation, providers must bill procedure codes A0428, Nonemergency transport, and A0425, Ground mileage, or A0429, Emergency transport, and A0425, Ground mileage, with modifier ET, Emergency Transport. Providers must bill the appropriate mileage with the appropriate base rate procedure code. For air transportation, providers must bill either with procedure codes A0430, Fixed wing, and A0435, Air mileage, or A0431, Rotary wing, and A0436, Air mileage. Providers must bill the appropriate mileage with the appropriate base rate procedure code. When submitting a claim for water transport services, providers are to use procedure code A0999, Unlisted ambulance service. The claim suspends for manual review and pricing. Night calls are no longer paid separately. The payment rates represent a global payment. It is inappropriate to bill for any supplies or other services related to the transport, unless otherwise specified in this section. The integrity of the information regarding the client s condition requiring the transport and the medical necessity of the transport are the responsibility of the ambulance provider. The ambulance provider may be sanctioned, including exclusion from the Medicaid Title XIX programs, for completing or signing a claim form that includes false or misleading representations of the client s condition or the medical necessity of the transport Prior Authorization All nonemergency transports require prior authorization. Emergency transports do not require prior authorization. All out-of-state (air and ground) transports require prior authorization from TMHP. To initiate the prior authorization process, providers are to call (tollfree; from 7 a.m. to 7 p.m., Monday through Friday, Central Time) before the transfer or on the first workday following transfers that occur after hours, on weekends, or on holidays. TMHP is responsible for granting prior authorization for all Primary Care Case Management (PCCM)-Texas Health Network members and all STAR+PLUS MQMBs Emergency Ambulance Services When the client s condition is life-threatening and requires use of special equipment, life support systems, and close monitoring by trained attendants while in route to the nearest appropriate facility, the ambulance transport is an emergency service. Examples of conditions considered for emergency transports include, but are not limited to, acute and severe illnesses, untreated fractures, loss of consciousness, semiconsciousness, seizure or with receipt of CPR during transport, acute or severe injuries from auto accidents, and extensive burns. Conditions requiring use of restraints for the safety of the client s or crew s safety may be considered emergencies. Providers must document the restraint type on the run sheet along with the documentation to support the medical necessity for the transport. 7 2

3 Ambulance Facility-to-facility transfers may be considered emergencies. Emergencies include medical conditions for which the absence of immediate medical attention could reasonably be expected to result in serious impairment, dysfunction, or failure of one or more organs or body parts, and the required emergency treatment is not available at the first facility. Claims for such transports must document the aforementioned criteria. Emergency transports do not require prior authorization Emergency Transport Billing When billing emergency transports, a minimum of one diagnosis description or the ICD-9-CM diagnosis code must be written on the claim form or in the diagnosis code field for electronic billers. TMHP does not process a claim that has see attached as the only information in the diagnosis block on the claim. The supporting documentation is critical for determining the client s condition. Providers must include all information that supports the reason for the transport and attach a copy of the run sheet to the claim. The emergency medical technician (EMT) who transported the client must sign the documentation. Important: Emergency transports that are denied cannot be accepted on appeal as nonemergency transfers. Note: Emergency and nonemergency claims may be billed electronically to Medicaid. For electronic billers, the hospital s TPI must be entered in the facility ID field. Providers should consult with their software vendor for the location of this field on the electronic claim form. All emergency claims submitted on paper are required to have the following documentation: Ambulance run sheet (must include the signature of the EMT transporting the client), facility transferring records, or emergency room records. Distance of transport traffic patterns. Time of transport. Acuity of client. Electronic billers must insert this information into the comment field, along with the client s blood pressure, pulse, and respiration readings if vital signs are abnormal. The comment field is only 40 bytes long. Condition Codes Electronic billers should use as many Condition Codes as needed to fully describe the patient s condition. Condition Code 60 is used to notify TMHP that the patient was taken to the nearest facility. Condition Code Description 01 Patient was admitted to a hospital 02 Patient was bed-confined before the ambulance service 03 Patient was bed-confined after the ambulance service 04 Patient was moved by stretcher 05 Patient was unconscious or in shock Condition Code Description 06 Patient was transported in an emergency situation 07 Patient had to be physically restrained 08 Patient had visible hemorrhaging 09 Ambulance service was medically necessary 60 Transportation was to the nearest facility Emergency transports billed as nonemergency services are denied. These transports may be appealed as emergency claims only. All claims submitted on paper or electronically must include the two-digit origin and destination codes. The origin is the first digit, and the destination is the second digit. The following are the origin and destination codes: Code D E G H I J N P R S X Description Diagnostic or therapeutic site other than P or H when these are used as origin codes Residential, domiciliary, custodial facility (other than an 1819 facility) Hospital-based dialysis facility (hospital or hospital-related) Hospital Site of transfer (e.g., airport or helicopter pad) between modes of ambulance transport Nonhospital-based dialysis facility Skilled nursing facility (SNF) (1819 facility) Physician s office (includes HMO nonhospital facility, clinic, etc.) Residence Scene of accident or acute event (Destination code only) Intermediate stop at physician's office en route to the hospital (includes HMO nonhospital facility, clinic, etc.) Nonemergency Ambulance Services When the client has a medical problem requiring treatment in another location and is so severely disabled that the use of an ambulance is the only appropriate means of transport, the ambulance transport is a nonemergency service. Nonemergency transports for a Medicaid client with severe disabilities must be to or from a scheduled medical appointment or for discharge from the hospital. Severely disabled means that the client s physical condition limits mobility and requires the client to be bedconfined at all times or unable to sit unassisted at all times, or requires continuous life-support systems (including oxygen or IV infusion) or monitoring of unusual physical or chemical restraint

4 Section 7 A round-trip transport from the client s home to a scheduled medical appointment (for example, an outpatient or freestanding dialysis or radiation facility) is a covered service when the client meets the definition of severely disabled. All nonemergency ambulance transfers to a scheduled doctor s appointment require the doctor s name and address, the diagnosis, and the treatment rendered at the time of visit. Nonemergency transports of clients with conditions that do not meet the severely disabled criteria are not a covered service. Refer to: Medical Transportation on page L-1 for more information about nonemergency transportation Nonemergency Ambulance Transports Medicaid healthcare providers (for example, physicians, hospitals, nursing facilities) are responsible for providing or arranging nonemergency transportation for their severely disabled Medicaid clients. Arranging nonemergency transportation for these clients is required by the Medicaid program and includes obtaining prior authorization for the transport. Healthcare providers must request prior authorization before contacting the ambulance provider for the transport. Note: Ambulance providers may choose to bill healthcare providers who fail to provide appropriate authorization (the prior authorization number) for nonemergency transports. Ambulance providers may assist hospitals, physicians, and other healthcare providers in obtaining prior authorizations. Providers may contact the TMHP Ambulance Unit at or their provider relations representative with questions about the nonemergency ambulance transport policy. To request prior authorization for a nonemergency transport, providers are to fax the request to the TMHP Ambulance Unit at Nonemergency Ambulance Transport Prior Authorization Prior authorization is required for all nonemergency ambulance transports. TMHP responds to prior authorization requests within 48 hours of receipt of the request. It is recommended that all requests for a prior authorization number (PAN) be submitted in sufficient time to allow TMHP to issue the PAN before the date of the requested transport. Documentation of a client s condition that meets the severely disabled definition must be provided at the time of request. Prior authorization is a condition for reimbursement but is not a guarantee of payment. The client and provider must meet all the Medicaid requirements such as eligibility and filing deadlines. These prior authorization requirements also apply to Medicaid providers participating in the PCCM-Texas Health Network. Medicaid providers participating in one of the Medicaid managed care HMO plans must follow the requirements of their plan. Prior authorizations for nonemergency transports require supporting documentation. The TMHP Ambulance Unit reviews the documentation to determine if the client meets the definition of severely disabled. Incomplete information may cause the request to be denied. The following information assists TMHP in determining the appropriateness of the transport: A detailed explanation of the severity of the client s physical condition that established the medical necessity for transport. If the client is bed-confined, documentation must clearly state the reasons for the confinement. The necessary equipment, treatment, or personnel used during the transport. The origination and destination points of the client s transport. Important: TMHP continues to require prior authorization for all out-of-state ambulance transfers. When the client does not meet the severely disabled criteria, nonemergency ambulance services are not covered Prior Authorization Process Medicaid healthcare providers and TMHP follow the following prior authorization process: 1) The ambulance provider seeks prior authorization for a nonemergency transport. The client s physician, nursing or ICF-MR facility, healthcare provider, or other responsible party faxes a copy of the Ambulance Fax Cover Sheet on page D-4 to the TMHP Ambulance Unit at Information and documentation listed on the form must be sent with the request before the transport to the initial or next medical appointment. Documentation requirements are outlined in this section under Supporting Documentation on page ) TMHP reviews all information and documentation received and a letter of approval or denial is faxed to the requesting provider. The client is notified by mail if the authorization request is denied or downgraded. Reasons for denial include documentation that does not meet the severely disabled criteria or the client is not eligible for the dates of services requested. Clients may appeal prior authorization request denials by contacting TMHP Client Notification at ) The requester contacts the transporting ambulance company and provides the company with the PAN and the dates of service approved. 4) Ambulance providers must attempt to obtain the PAN before transporting the client. Claims submitted without the PAN are denied and must be appealed in writing by the provider. The appeals must be accompanied by supporting documentation. The ambulance provider must document attempts to obtain the PAN from the client or the healthcare provider before transporting the client. When the ambulance provider 7 4

5 Ambulance is unable to obtain the PAN, the provider can do one of the following: Transport the client and appeal the denied claim with documentation of severe disability and evidence of a previous and timely PAN request. Transport the client and bill the healthcare provider who failed to provide the appropriate authorization. 5) Hospitals may call TMHP at or fax to to obtain a PAN when discharging a client or transporting the client to another facility. Ambulance companies may provide documentation to assist hospitals in obtaining authorization, by fax only. Important: Claims submitted without the PAN are denied and must be appealed by the provider Authorization of Retroactive Eligibility Prior authorization is issued to clients who meet Medicaid eligibility and the severely disabled criteria. If a request for a PAN is received and the client s Medicaid coverage is pending, the request will be denied. The client s eligibility may be granted retroactively. The requestor has 95 days from the date the eligibility is added to TMHP s files to contact the Ambulance Unit and request authorization to be reconsidered. To inquire about Medicaid eligibility, providers are to contact the Automated Inquiry System (AIS) at or the TMHP EDI Help Desk at Prior Authorization Types, Definitions Short Term Short-term prior authorizations are issued to a client whose condition meets the severely disabled criteria for a short period of time. The length of the prior authorization is determined based on the treating physician s or surgeon s prognosis of recovery. If a recovery period cannot be determined at the time the prior authorization is requested, the TMHP Ambulance Unit defaults the authorization to 60 days with the option for an extension based on updated documentation received before the 60 days have lapsed. Hospital-to-hospital and hospital-tooutpatient medical facility transports are issued a PAN for that transport only. If the client already has a short-term or annual PAN, the PAN may be used for the ambulance transport. The hospital is responsible for obtaining the prior authorization. Annual Annual prior authorizations are issued to a client who meets the severely disabled criteria and whose condition is not expected to improve within the year. These authorizations are valid for a 12-month period as long as all other eligibility criteria are met. 180-Day 180-day prior authorizations are issued to a client and are granted within 24 hours from the time received, excluding weekends and holidays for authorization of nonemergency ambulance services. The request must be effective for a period of 180 days from the date of issuance if the request includes a written statement from a physician. Requests can be submitted up to 60 days before the date of service. The provider requesting this authorization is required to complete the certification form on page D-64 in its entirety. Incomplete forms are not considered as a valid authorization request and are returned with a denial letter. The Physician Certification form are not considered as documentation after the service is rendered and should not be sent with a claim or an appeal Supporting Documentation Providers must submit supporting documentation (examples follow) with all prior authorization requests. Admit and discharge records with prognosis, including emergency room records A history and physical completed within six months or a care plan detailing daily activities from a facility or home health agency A letter on the healthcare provider s letterhead including the patient s primary mode of mobility and diagnosis history In hospital-to-hospital transports or hospital-to-outpatient medical facility transports, the Ambulance Unit considers information by telephone from the hospital. TMHP may request the hospital to fax the supporting documentation when available Claim Denials and Appeals Ambulance claims submitted without the PAN are denied and must be appealed on paper by the provider. The appeal must be accompanied by supporting documentation. Clients may appeal PAN request denials by contacting TMHP Client Notification at Important: All ambulance denials (air or ground) must be appealed on paper. Telephone and electronic appeals are not accepted. For claims or appeals related to prior authorization denials for the 180-day authorization request, the Physician Certification Form is not considered as documentation after the service is rendered. Refer to: Supporting Documentation on page

6 Section Ambulance Disposable Supplies Reimbursement for disposable supplies is separate from the established global fee for ambulance transports. Providers should use one procedure code, 9-A0382, to combine all payable disposable supplies used (for example, gauze, bandages, tape, suction catheter, gloves, and mask) during emergency and nonemergency ambulance transports. Reimbursement for this procedure code is limited to a maximum of $20.30 per transport (one-way) and $40.60 round trip. A maximum of two-supply procedure codes are allowed per round trip. In situations involving multiple transports on the same date of service, the provider may appeal claims denied because they exceed two-supply procedure codes per claim. When billing for nonpayable supplies, providers must bill the appropriate national code. Providers must provide medically necessary supplies for the client s safe transport Waiting Time Procedure code 9-A0420, Ambulance waiting 1/2 hr, may be billed when it is the general billing practice of local ambulance companies to charge for unusual waiting time (longer than 30 minutes). Providers must use the following procedures: Separate charges must be billed for all clients, Medicaid and non-medicaid, for unusual waiting time. The circumstances requiring waiting time and the exact time involved must be documented in Block 24 of the HCFA-1500 claim form. The amount charged for waiting time must not exceed the charge for a one-way transfer. Important: Waiting time is reimbursed up to one hour Extra Attendant or Registered Nurse Charges for an extra attendant or registered nurse (in addition to the two-person crew) for an ambulance transfer are reimbursed when the claim documents the necessity of advanced life-support services (for example, procedure code 9-A0424). Without documentation of the medical need of the third attendant, the third attendant s services are not reimbursable. Medicaid does not reimburse based on each ambulance provider s internal policy Night Call Ambulance providers billing an extra charge for Night Call is not reimbursed separately. 7.4 Membership Fees The Texas Insurance Code does not apply to ambulance providers who finance, in part or in whole, the ambulance service by subscription. HHSC s Bureau of Emergency Management and Bureau of Policy and Operations have specific guidelines about these subscription plans. For more information, providers may contact their regional EMS program administrator or the HHSC Emergency Medical Services Division at Types of Transport Multiple Client Transports Multiple client transports occur when more than one client with Medicaid coverage is transported in the same vehicle simultaneously. A claim for each client must be completed and must reference multiple transfers with the names and Medicaid numbers of other clients sharing the transfer in Block 19 of the HCFA-1500 claim form. Providers must enter charges on a separate claim for each client. TMHP adjusts the payment to 80 percent of the allowable base rate for each claim and divides mileage equally among the clients who share the ambulance. Important: Mileage determinations are based on the Official State Mileage Guide. Refer to: Claims Filing Instructions on page Out-of-Locality Transports Transports to out-of-locality providers are covered if a local facility is not adequately equipped to treat the condition. Out-of-locality refers to one-way transfers of 50 or more miles from point of pickup to point of destination. Important: Transports may be cut back to the closest appropriate facility Air or Boat Transports Air ambulance transport services, by means of either fixed or rotary wing aircraft, may be covered only if one of the following conditions exists: The client s medical condition requires immediate and rapid ambulance transportation that could not have been provided by ground ambulance. The point of client pick-up is inaccessible by ground vehicle. Great distances or other obstacles are involved in transporting the client to the nearest appropriate facility. Important: Air transport claims may be submitted on paper with supporting documentation. Claims may be submitted electronically with a short description of the client s physical condition in the comment field. If the client s condition cannot be documented, providers must file a paper claim. Emergency ambulance transport claims that are denied because they do not meet the emergency air or boat medical necessity criteria, but do meet emergency ground criteria, are considered for payment at the appropriate ground rate. 7 6

7 Ambulance Pregnancy Transports Transporting a pregnant woman may be covered as an emergency transfer if the client s condition is documented as an emergency situation at the time of transfer. Claims documenting a home delivery or delivery en route are considered emergency transfers. Premature labor and early onset of delivery (less than 37 weeks gestation) also may be considered an emergency. Active labor without more documentation of an emergency situation is not payable as an emergency transport. Important: First day of last menstrual period (LMP) or estimated due date (EDD) must be in Block 14 of the claim form and on the documentation. If the pregnant client is transported in an ambulance on a nonemergency basis, all criteria for nonemergency prior authorization must be met Transports to or From State Institutions Ambulance transports to or from a state-funded hospital for admission or following discharge are covered when nonemergency transfer criteria are met. Ambulance transfers of clients while they are inpatients of the institution are not covered. The institution is responsible for routine nonemergency transportation. Transports from a nursing facility to a hospital are covered if the client s condition meets emergency criteria. Nonemergency transfers for the purpose of required diagnostic or treatment procedures not available in the nursing facility (such as dialysis treatments at a freestanding facility) are also allowable only for clients meeting the definition of severely disabled. Transports of nursing facility residents for rehabilitative treatment (for example, physical therapy) to outpatient departments or physicians offices for recertification examinations for nursing facility care are not reimbursable ambulance services. The nursing facility is responsible for providing routine nonemergency transportation for services not provided in the nursing facility. The cost of such transportation is included in the nursing facility vendor rate. Claims for services to nursing facility residents must indicate the medical diagnosis or problem requiring treatment, the medical necessity for use of an ambulance for the transport, and the type of treatment rendered at the destination (for example, admission or X-ray). If a client is returned by ambulance to a nursing facility following hospitalization, the acute condition requiring hospitalization must be noted on the ambulance claim form. This transport is only considered for payment if the client meets the severely disabled criteria. Nursing facilities are responsible for providing or arranging transportation for their residents. Arranging transportation for Medicaid clients includes obtaining prior authorizations for nonemergency ambulance transports. Ambulance providers may assist nursing facilities in obtaining prior authorizations. Ambulance providers may only bill a nursing facility or client for a nonemergency ambulance transport under the following circumstances: Providers are to bill the nursing facility when the nursing facility requests the nonemergency ambulance transport without a prior authorization number. Providers are to bill the client only when the client requests transport that is not an emergency, and the client does not meet the severely disabled criteria. The provider must advise the client of acceptance as a private pay patient at the time the service is provided, and the client is responsible for payment of all services. Providers are encouraged to have the client sign the Private Pay Agreement. Providers may refer questions about a nursing facility s responsibility for payment of a transport to the TMHP Ambulance Unit at or TMHP provider relations representatives Hospice Program Refer to: Hospice Program on page 1-7 for information on the Medicaid Hospice Program Transports for Nursing Facility Residents Spend Down Refer to: Spend Down Processing on page 1-10 for information on the Spend Down Program. 7.6 Medicare/Medicaid Coverage Medicaid is the secondary payor to other health insurance sources including Medicare. Ambulance claims for Medicaid and Medicare Part B claims must be filed with Medicare first. Medicare Qualified Medicaid Beneficiaries (MQMBs) are eligible for Medicaid benefits such as ambulance transports. Qualified Medicare Beneficiaries (QMBs) are not eligible for Medicaid benefits. The Medicaid program is only required to pay for coinsurance and/or deductible for QMBs. Therefore, providers should not request prior authorization for ambulance services for these clients. Important: Providers must use national procedure codes when billing Medicaid. Refer to: Medicare/Medicaid Clients on page Medicare Paid Assigned claims filed with and paid by Medicare are automatically transferred to TMHP for payment of the deductible and coinsurance liability. 7 7

8 Section 7 Providers must submit Medicare-paid claims that do not cross over to TMHP for the coinsurance and deductible. Providers must send the Medicare Remittance Advice (RA) with the client information circled in black ink Medicare Denied All claims denied by Medicare for administrative reasons must be appealed to Medicare before sending to Medicaid. An assigned claim denied by Medicare because the client has no Part B benefits, or because the transport destination is not allowed, can be submitted to TMHP for consideration. Providers must send claims to TMHP on a HCFA-1500 with the ambulance TPI unless they are a hospital-based provider. If so, providers must file the claim on a UB-92 with the hospital TPI. Note: All claims for STAR+PLUS clients with Medicare and Medicaid should follow the same requirements noted in Prior Authorization on page 7-2, including obtaining prior authorization for Medicaidonly services from TMHP. The STAR+PLUS HMO is not responsible for reimbursement of these services. 7.7 Relation of Service to Time of Death Medicaid benefits cease at the time of the client s death. However, if the client dies in the ambulance while en route to the destination, Medicaid covers the transport. If a physician pronounces the client dead after the ambulance is called, Medicaid covers the ambulance service (base rate plus mileage) to the point of pickup. Providers must Indicate the date and time the client died in Block nine of the HCFA claim form. If a physician or coroner pronounces the client dead before the ambulance is called, the service is not covered. Important: Equipment and supplies are included in the base rate. They are not separately reimburseable, but are considered part of another procedure. As such, they may not be billed to the client. 7.8 Ambulance Procedure Codes Use the following procedure codes when billing for ambulance services provided to Medicaid-eligible clients: Emergency Code Description Maximum Fee 9-A0382 Basic support routine suppls Note: Maximum allowable fee of $20.30 is per transport, not to exceed $40.60 round trip. $ A0420 Ambulance waiting 1/2 hr * 9-A0422 Ambulance 02 life sustaining * 9-A0424 Extra ambulance attendant * 9-A0425 with modifier ET Ground mileage Note: Use modifier ET to denote emergency services. A0425-ET will be denied if it is billed without A A0429 BLS-emergency * 9-A0430 Fixed wing air transport $1, A0431 Rotary wing air transport $ A0435 Fixed wing air mileage $ A0436 Rotary wing air mileage $ A0999 Unlisted ambulance service Note: Use for water ambulance services. MP *Reimbursed at reasonable charge, which is the lesser of the provider s customary profile, the prevailing profile, or the provider s actual charge in accordance with 1 TAC * 7 8

9 Ambulance Nonemergency Code Description Maximum Fee 9-A0382 Basic support routine suppls Note: Maximum allowable fee of $20.30 is per transport, not to exceed $40.60 round trip. $ A0420 Ambulance waiting 1/2 hr * 9-A0422 Ambulance 02 life sustaining * 9-A0424 Extra ambulance attendant * 9-A0425 Ground mileage * Note: A0425 will be denied if it is billed without A A0428 BLS * *Reimbursed at reasonable charge, which is the lesser of the provider s customary profile, the prevailing profile, or the provider s actual charge in accordance with 1 TAC Claims Information Providers must submit ambulance services to TMHP on a HCFA-1500 claim form. Providers must purchase HCFA-1500 claim forms from a vendor of their choice; TMHP does not supply them. Providers may file emergency and nonemergency ambulance services claims to TMHP in an approved electronic format. Nonemergency claims filed electronically must include the PAN in the appropriate field (DA0.14). Reminder: Providers must submit multiple transports for the same client on the same date of service through one claim submission. Refer to: Reimbursement Methodology on page Modifiers on Ambulance Claims Ambulance providers may see the HH modifier on their Remittance and Status (R&S) reports, which indicates the transfer is from a noncontracted to a contracted hospital. It does not affect claim payment or processing. Modifier TG, Complex/high tech level of care, may be used to indicate ALS services were provided when billing BLS procedure codes Claim Filing Resources Providers may refer to the following sections or forms when filing claims: Resource Page Number HCFA-1500 Claim Filing Instructions 4-20 Communication Guide A-1 Automated Inquiry System (AIS) User s Guide B-1 TMHP EDI General Information C-1 Ambulance Claim Example 1 F-3 Ambulance Claim Example 2 F-4 Ambulance Claim Example 3 F-4 Acronym Dictionary I-1 7 9

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