Suppliers of Ambulance Services

10.2.2.10 – Suppliers of Ambulance Services (Rev. 11891; Issued: 03-09-23; Effective: 04-21-23; Implementation: 06-19-23) Suppliers of ambulance services are supplier types that enroll via the Form CMS-855B. A. General Background Information It is important that the contractor review and adhere to the following regulations and instructions regarding the required qualifications of ambulance suppliers: • 42 CFR §§ 410.40 and 410.41 • 42 CFR Part 414, subpart H • Pub. 100-02, chapter 10 • Pub. 100-04, chapter 15 B. Types of Ambulance Services As stated in 42 CFR § 410.40(c), there are several levels of ambulance services covered by Medicare. They are generally defined in § 414.605 and in Pub. 100-02, chapter 10, section 30.1 as follows: 1. Advanced Life Support, level 1 (ALS1) - Transportation by ground ambulance vehicle, medically necessary supplies and services, and either an ALS assessment by ALS personnel or the provision of at least one ALS intervention. 2. Advanced Life Support, level 2 (ALS2) - Either transportation by ground ambulance vehicle, medically necessary supplies and services, and the administration of at least three separate administrations of one or more medications by intravenous push/bolus or by continuous infusion, excluding crystalloid, hypotonic, isotonic, and hypertonic solutions (Dextrose, Normal Saline, Ringer's Lactate); or ground ambulance transport, medically necessary supplies and services, and the provision of at least one of the seven ALS procedures specified in the definition of “Advanced Life Support, level 2” in § 414.605. 3. Air Ambulance (Fixed-Wing and Rotary-Wing) (See § 414.605 and Pub. 100-02, chapter 10, section 30.1.1.for specific definitions of fixed-wing and rotary-wing.) 4. Basic Life Support (BLS) - Transportation by ground ambulance vehicle and medically necessary supplies and services, plus the provision of BLS ambulance services. The ambulance must be staffed by at least two people who meet the requirements of state and local laws where the services are being furnished and where at least one of the staff members must be certified, at a minimum, as an emergency medical technician-basic (EMT-Basic) by the state or local authority where the services are furnished and be legally authorized to operate all lifesaving and life-sustaining equipment on board the vehicle. 5. Paramedic ALS Intercept Services (PI) - Per § 414.605, EMT-Paramedic services furnished by an entity that does not furnish the ground transport, provided that the services meet the requirements in § 410.40(d). In general, PI involves an arrangement between a BLS ambulance supplier and an ALS ambulance supplier, whereby the latter provides the ALS services and the BLS supplier provides the transportation component. Under § 410.40(d)(1) through (3), respectively, PI must meet the following requirements: • Be furnished in an area that is designated as a rural area (see § 410.40(d)(1) for more information on this requirement). • Be furnished under contract with one or more volunteer ambulance services that meet the following conditions: (1) are certified to furnish ambulance services as required under § 410.41; (2) furnish services only at the BLS level; and (3) be prohibited by state law from billing for any service. • Be furnished by a paramedic ALS intercept supplier that meets the following conditions: (1) is certified to furnish ALS services as required in § 410.41(b)(2); and (2) bills all the beneficiaries who receive ALS intercept services from the entity, regardless of whether or not those beneficiaries are Medicare beneficiaries. 6. Specialty Care Transport (SCT) - Inter-facility transportation of a critically injured or ill beneficiary by a ground ambulance vehicle, including medically necessary supplies and services, at a level of service beyond the scope of the EMT-Paramedic. SCT is necessary when a beneficiary's condition requires ongoing care that must be furnished by one or more health professionals in an appropriate specialty area (e.g., emergency or critical care nursing, emergency medicine, respiratory care, cardiovascular care, or an EMT-Paramedic with additional training). C. Ambulance Qualifications 1. Vehicle Design and Equipment Section 410.41(a) states that a vehicle used as an ambulance must meet the following requirements: • Be specially designed to respond to medical emergencies or provide acute medical care to transport the sick and injured and comply with all state and local laws governing an emergency transportation vehicle. • Be equipped with emergency warning lights and sirens, as required by state or local laws. • Be equipped with telecommunications equipment as required by state or local law to include, at a minimum, one two-way voice radio or wireless telephone. • Be equipped with a stretcher, linens, emergency medical supplies, oxygen equipment, and other lifesaving emergency medical equipment as required by state or local laws. 2. Vehicle Personnel Per 42 CFR § 410.41(b)(1), a BLS vehicle must be staffed by at least two people who meet the requirements of state and local laws where the services are being furnished, and at least one of the staff members must be: (i) certified at a minimum as an emergency medical technician-basic by the state or local authority where the services are furnished; and (ii) legally authorized to operate all lifesaving and life-sustaining equipment on board the vehicle. Per 42 CFR § 410.41(b)(2), an ALS vehicle must be staffed by at least two people who meet the requirements of state and local laws where the services are being furnished, and at least one of the staff members must: (i) meet the BLS vehicle staff requirements described in 42 CFR § 410.41(b)(1); and (ii) must also have one of the two staff members be certified as a paramedic or an emergency medical technician by the state or local authority where the services are being furnished to perform one or more ALS services. D. Completion of the Form CMS-855B Pub. 100-02, chapter 10, section 10.1.3 states that, in determining whether the vehicles and personnel of the ambulance supplier meet all of the above requirements, the contractor may accept the supplier’s statement (absent information to the contrary) that its vehicles and personnel meet all of the requirements if the statement itself meets the requirements of section 10.1.3. However, section 10.1.3 does not obviate the need for the supplier to complete and submit to the contractor the Form CMS-855B (including Attachment 1 and all supporting documents), and does not excuse the contractor from having to verify the data on the Form CMS-855B in accordance with this chapter and all other applicable CMS instructions. In other words, the “statement” referred to in section 10.1.3 does not supplant or replace the Form CMS- 855B enrollment process. E. Geographic Area: Single Contractor Jurisdiction If an ambulance supplier will furnish all of its services in the same contractor jurisdiction, the supplier should list: • Each site at which its vehicles are garaged in Section 4A. (The site is considered a practice location for enrollment purposes, including with respect to payment of the application fee.) • Each site from which its personnel are dispatched in Section 4A. (The site is considered a practice location for enrollment purposes, including with respect to payment of the application fee.) • Its base of operations – which, for ambulance companies, is their primary headquarters – in Section 4E. (The supplier can only have one base of operations.) If the supplier will furnish services in more than one contractor jurisdiction, the applicable instructions in sections 10.2.2.10(F) and (G) and 10.3.1(B)(1)(d)(iii) of this chapter apply. F. Geographic Area: Multiple States The supplier must list the geographic areas in which it provides services. If the supplier indicates that it furnishes services: • In more than one contractor's jurisdiction, it must submit a separate Form CMS-855B to each contractor. • In more than one state but within the same contractor jurisdiction, the contractor shall review sections 10.2.2(G)(7), 10.3, and 10.3.1(B)(1)(d)(iii) of this chapter to determine whether a separate enrollment for the additional state is required. G. Practice Locations For purposes of provider enrollment (and as indicated in section 10.2.2.10(E) above), the following are considered ambulance “practice locations”: • A site at which the supplier’s vehicles are garaged • A site from which the supplier’s personnel are dispatched • The supplier’s base of operations (i.e., the supplier’s primary headquarters). The supplier can only have one base of operations. Hence, if an ambulance supplier submits a Form CMS-855B to add to its enrollment record a site at which the supplier’s vehicles are garaged or from which personnel are dispatched, the supplier must pay an application fee. Consider the following scenarios: a. The ambulance supplier is enrolling and performing services in multiple states but within only one contractor jurisdiction: The supplier would have to list on its Form CMS-855B each city/state/zip code in which it performs services. Its base of operations and all other practice locations would also have to be listed, and all licensure/certification requirements would have to be met for each state in which it performs services. However, separate Form CMS-855B applications for each state would only be required if all five conditions described in section 10.3.1(B)(1)(d)(iii) of this chapter are met. b. The ambulance supplier is enrolling (and has its base of operations) in Contractor Jurisdiction X. Its vehicles perform services in X and in adjacent Contractor Jurisdiction Y: The supplier would have to enroll with X and Y. For its Contractor X Form CMS-855B, the supplier would have to list all of the data mentioned in Example (a) above. For its Contractor Y Form CMS- 855B, the supplier would have to (1) list the cities/zip codes in Y in which it performs services, (2) list its Jurisdiction X base of operations and any practice locations in Jurisdiction Y, and (3) meet all licensure/certification requirements for the state(s) in Y in which the supplier performs services. H. Licensure Information With respect to licensure: • The contractor shall ensure that the supplier is appropriately licensed and/or certified, as applicable. • An air ambulance supplier that is enrolling in a state to which it flies in order to pick up patients (that is, a state other than where its base of operations is located) is not required to have a practice location or place of business in that state. So long as the air ambulance supplier meets all other criteria for enrollment in Medicare, the contractor for that state may not deny the supplier's enrollment application solely on the grounds that the supplier does not have a practice location in that state. (This policy only applies to air ambulance suppliers.) I. Paramedic Intercept Information If the applicant indicates that it has a paramedic intercept arrangement, it must include a copy of the agreement/contract with its application. J. Air Ambulances Air ambulance suppliers must submit proof that it or its leasing company possesses a valid charter flight license (FAA Part 135 Certificate) for the aircraft being used as an air ambulance. Any of the following constitutes acceptable proof: • If the air ambulance supplier or provider owns the aircraft, the owner's name on the FAA Part 135 certificate must be the same as the supplier's or provider’s name on the enrollment application. • If the air ambulance supplier or provider owns the aircraft but contracts with an air services vendor to supply pilots, training, and/or vehicle maintenance, the FAA Part 135 certificate must be issued in the name of the air services vendor. A certification from the supplier or provider must also attest that it has an agreement with the air services vendor and must list the date of that agreement. A copy of the FAA Part 135 certificate must accompany the enrollment application. • If the air ambulance supplier or provider leases the aircraft from another entity, a copy of the lease agreement must accompany the enrollment application. The name of the company leasing the aircraft from that other entity must be the same as the supplier's or provider’s name on the enrollment application. The air ambulance supplier shall maintain all applicable federal and state licenses and certifications, including pilot certifications, instrument and medical certifications, and air worthiness certifications. In addition: • The contractor shall access the following FAA Web site on a quarterly basis to validate all licenses/certifications of air ambulance operators that are enrolled with the contractor: https://www.faa.gov/about/office_org/headquarters_offices/agc/practice_areas/enforceme nt/reports/. This helps ensure that the supplier’s licenses/certifications are active and in good-standing. • The contractor shall deny or revoke the enrollment of an air ambulance supplier if the supplier does not maintain its FAA certification or any other applicable licenses. • Section 424.516(e)(3) states that within 30 days of any revocation or suspension of a federal or state license or certification (including an FAA certification), an air ambulance supplier must report the revocation or suspension of its license or certification to the applicable Medicare contractor. The following FAA certifications must be reported: (i) specific pilot certifications including, but not limited to, instrument and medical certifications; and (2) airworthiness certification. K. Hospital-Based Ambulances An ambulance service that is owned and operated by a hospital need not complete a Form CMS- 855B if: • The ambulance services will appear on the hospital’s cost-report; and • The hospital possesses all licenses required by the state or locality to operate the ambulance service. If the hospital decides to divest itself of the ambulance service, the latter will have to complete a Form CMS-855B if it wishes to bill Medicare.