(A) Payment may be made for the following ground ambulance services:
(1) Basic life support, provided in a non-emergency (BLS non-emergency);
(2) Basic life support, provided in an emergency (BLS emergency);
(3) Advanced life support, level 1, provided in a non-emergency (ALS1 non-emergency);
(4) Advanced life support, level 1, provided in an emergency (ALS1 emergency);
(5) Advanced life support, level 2 (ALS2);
(6) Specialty care transport (SCT);
(7) Mileage, ground ambulance; and
(8) Attendant services, ground ambulance.
(B) Payment may be made only if all the requirements in this paragraph are met.
(1) The necessity of ground ambulance service is established.
(a) Emergency ground ambulance services are deemed to be necessary. BLS emergency, ALS1 emergency, and associated loaded mileage are emergency services by definition. ALS2, specialty care transport, and associated loaded mileage are treated as emergency services.
(b) The non-emergency transfer by ground ambulance of a medicaid-eligible individual from one hospital to a second hospital is deemed to be necessary if two conditions apply:
(i) At least one of the criteria listed in paragraph (B)(1)(c) of this rule is met; and
(ii) The services provided at the second hospital are coverable by medicaid.
(c) The necessity of all other non-emergency ground ambulance services is determined by at least one of three criteria:
(i) The individual requires medical treatment or continuous supervision by an EMT during transport;
(ii) The individual requires the administration or regulation of oxygen by another person during transport; or
(iii) The individual requires supervised protective restraint during transport.
(2) The transport vehicle is a ground ambulance.
(3) The medicaid-eligible individual is transported either to or from a medicaid-coverable service.
(4) The medicaid-eligible individual is transported both to and from a recognized or approved point of transport.
(5) The services of an additional attendant are used only when such services are necessary for the safe transport of a medicaid-eligible individual. The transportation provider must maintain documentation of such necessity.
(C) A hospital that is an eligible provider may submit a claim for ground ambulance services on behalf of another entity if two conditions apply:
(1) The other entity is an eligible provider of ground ambulance services; and
(2) The hospital and the other entity have entered into an appropriate agreement or contract.
Replaces: Part of 5160-15-03
Five Year Review (FYR) Dates: 04/01/2021
Promulgated Under: 119.03
Statutory Authority: 5164.02
Rule Amplifies: 5164.02
Prior Effective Dates: 04/07/1977, 05/09/1986, 07/05/1993, 03/01/2000, 12/27/2001, 10/01/2003, 12/30/2005 (Emer), 03/27/2006