LAC 40:I.3911. Schedule of Maximum Allowances

A. This document provides the basis for identification of procedures to be reimbursed to transportation vendors. The coding source is the health care financing administration common procedure coding system (HCPCS). No other coding methodology will be accepted by the carrier/self-insured employer. Please do not bill using any of the modifiers. Modifiers will not affect payment and may cause your bill to be unnecessarily delayed. B. This fee schedule provides the basis for reimbursement of medical transportation. Reimbursement is limited to the least of: 1. the provider's usual and customary charge; 2. a reimbursement amount previously negotiated by the provider and the carrier/self-insured employer; or 3. the maximum allowable reimbursement as determined by the following schedule. State of Louisiana Office of Workers' Compensation Schedule of Maximum Allowances for Medical Transportation HCPCS | Description | Maximum Allowable A0140 | Nonemergency Transportation and Air Travel (Private or Commercial), Intra or Interstate | B.R. A0999 | Unlisted Ambulance Service | B.R. A0380 | Emergency Ambulance Service, BLS per Mile, One Way | $6 A0390 | Emergency Ambulance Service, (ALS) Per Mile, One Way | $7 A0420 | Ambulance Service, Waiting Time, One Half (1/2) Hour Increments, Rate per Unit (See Table Below) | $42 A0422 | Ambulance Service, Oxygen, Administration and Supplies, Life Sustaining Situation | B.R. A0427 | Emergency Ambulance Service, Advanced Life Support (ALS) Base Rate, All Inclusive Services, One Way | $375 A0428 | Nonemergency Transportation, Ambulance, Base Rate, One Way | $169 A0429 | Emergency Ambulance Service, BLS Rate One Way | $258 A0430 | Ambulance Service, Conventional Air Service One Way | B.R. A0431 | Ambulance Service, Air, Helicopter, v | B.R.