Ambulance Services

Overview

Ambulance services include emergency and non-emergency ambulance services.

Eligible Providers

Eligible providers must be licensed as a transportation service provider for advanced life support, basic life support, or scheduled life support.

Eligible Members

Members in the following programs are eligible for emergency and non-emergency ambulance services:

• Families and Children
• Minnesota Senior Care Plus (MSC+)
• Special Needs BasicCare (SNBC)
• Prime Health Complete (HMO SNP)
• PrimeWest Senior Health Complete (HMO SNP)
• MinnesotaCare

Covered Services

PrimeWest Health covers ambulance services when the member’s transportation is for the following:

1. In response to a 911 emergency call, a police or fire department call, or an emergency call received by the provider
2. Between two facilities, only when the first facility discharges the member to another facility because the first facility could not provide the level of care required by the member
   1. Includes emergency and non-emergency ambulance transport
3. Medically necessary and documented as defined in Prehospital Care Data
4. A transfer of an infant from an NICU level II or III nursery to a hospital near the family’s home, if the distance from the NICU facility to the family home is greater than 40 miles

If a member is pronounced dead by a legally authorized person, the following are true:

1. After transportation is called, but before it arrives, service to the point of pickup is covered
2. En route, or dead on arrival, the transportation is covered
3. Before transportation is called, transportation is not covered

PrimeWest Health covers ambulance no-load transportation only if the ambulance transportation staff provided medically necessary treatment to the member at the pickup point.

Air Ambulance Guidelines

PrimeWest Health covers air ambulance when the following criteria are met:

1. The member has a potentially life-threatening condition that does not permit the use of another form of ambulance transportation
2. The referring facility does not have adequate facilities to provide the medical services needed by the member
3. Transport must be to the nearest appropriate facility capable of providing the level of care required by the member

Air ambulance transportation requires a Service Authorization only if either the originating or final destination is an out-of-state non-contracted facility.

If medical necessity is not proven and proper documentation does not exist, air ambulance transportation for a member not having a potentially life-threatening condition will be denied and must be resubmitted as ground ambulance transportation.

Ground Ambulance Guidelines

PrimeWest Health covers ground ambulance when the following criteria are met:

1. The member has a potentially life-threatening condition that does not permit the use of another form of transportation
2. Service is medically necessary
3. The referring facility does not have adequate facilities to provide the medical services needed by the member
4. Transport must be to the nearest appropriate facility by the most direct route

Ambulance Transportation Authorization Requirements

Non-emergency Ambulance Trips

Request authorization from PrimeWest Health for non-emergency ambulance transports for members who will be transported for more than six one-way trips (three round trips) during a single calendar month.

Include the appropriate mileage code and total miles when requesting authorization for air or non-emergency transports.

Ground Ambulance

Submit the ground ambulance claims with the “Origin” and “Destination” indicators (modifiers) to indicate the transport is from and to any of the following:

1. Hospitals (HH)
2. Skilled Nursing Facilities (NN)
3. Residential, Domiciliary, or Custodial Facilities (EE)
4. Diagnostic or Therapeutic Sites (DD)
5. Hospital based ESRD facilities (GG)
6. Freestanding ESRD facilities (JJ), also GJ and JG
7. Site of Transfer to Site of Transfer (II)

Also note the following when billing for ground ambulance transport:

1. Submit procedure code A0998 (ambulance response and treatment, no transport) without a modifier
2. Use the appropriate ambulance transport service code to indicate the level of ambulance transport service provided.

Refer to the following exceptions from the personal mileage requirement:

1. Member has a medical condition that prevents the safe operation of a motor vehicle
2. A qualified medical professional must provide documentation
3. Exclusion may be time limited
4. The transportation coordinator (county or tribal local agency, or entity hired to act on behalf of the county or tribe) may consider other reasonable exclusions for a vehicle being unavailable for use
5. Member must provide supporting documentation
6. Exclusion may be time limited

Personal mileage reimbursement requirements include:

1. Personal mileage requirements apply to the member and people who have a relationship (vested interest) to the member. This includes, but is not limited to, family, friends, relatives, neighbors, personal care assistants (PCA), home health aides (HHA), other personal attendants, corporate foster care staff, or county social worker.
2. The member must complete and submit personal mileage trip-log sheets for reimbursement. The local agency establishes trip-log submission deadlines. Trip logs must include the following:
   1. Member name and PrimeWest Health ID number
   2. Date of service
   3. Name of medical provider or facility
   4. Address of residence (trip origination location) and medical provider or facility (destination location)
   5. Verification of medical appointment. Acceptable verification may include a signature from the medical provider or facility or copy of the medical appointment explanation of benefits

PW_11-19_596
Updated_09/21/2021