Ambulance

(A) Criteria for Use. (1) Emergency Situations. Ambulance services are always covered in emergency situations. An emergency situation is defined as one in which the member has a critical or unknown illness or injury that apparently demands immediate medical attention at a hospital to prevent permanent injury or loss of life. Emergency cases must be transported to the nearest medical facility equipped for and capable of treating such emergency cases. (2) Nonemergency Situations. In nonemergency situations, ambulance services are covered when medically necessary as set forth in 130 CMR 407.481(B). The return trip of an emergency transport is considered to be a nonemergency situation. (B) Conditions Always Requiring Transportation by Ambulance. (1) Medical Conditions. A member who has any of the following medical conditions always requires transportation by ambulance: (a) continuous dependence on oxygen; (b) continuous confinement to bed; (c) classification as an American Heart Association Class IV patient with a disease of the heart: members with cardiac disease resulting in the inability to perform any physical activity without discomfort. Symptoms of cardiac insufficiency or of the anginal syndrome may be present even at rest. If any physical activity is undertaken, discomfort is increased; (d) receiving intravenous treatment; (e) after cardiac catheterization; or (f) having uncontrolled seizure disorders. (2) Orthopedic Conditions. A member who has either of the following orthopedic conditions always requires transportation by ambulance: (a) total body cast; or (b) hip spicas or other casts that prevent flexion at the hip. (3) Pediatric Conditions. A member who is in an isolette (incubator) always requires transportation by ambulance. (4) Psychiatric Conditions. A member who has either of the following psychiatric conditions always requires transportation by ambulance: (a) in need of restraints (possibly harmful to himself or herself or others, including persons transported under M.G.L. c. 123, § 12 for temporary hospitalization by reason of mental illness). As defined in M.G.L. c. 123, § 1, “likelihood of serious harm” is: “(1) substantial risk of physical harm to the person himself or herself as manifested by evidence of threats of, or attempts at, suicide or serious bodily harm; (2) a substantial risk of physical harm to other persons as manifested by evidence of homicidal or other violent behavior or evidence that others are placed in reasonable fear of violent behavior and serious physical harm to them; or (3) a very substantial risk of physical impairment or injury to the person himself or herself as manifested by evidence that such person's judgment is so affected that he or she is unable to protect himself or herself in the community and that reasonable provision for his or her protection is not available in the community.”; or (b) heavily sedated. (5) Neurological Conditions. A member who has any of the following neurological conditions always requires transportation by ambulance: (a) continual confinement to bed (because of severe brain damage, for example); or (b) comatose. (C) Medical Necessity Form Requirement. (1) Emergency ambulance trips do not require a Medical Necessity Form. However, the nature of the emergency must be supported by medical records at the hospital to which the member was transported. (2) Nonemergency ambulance transportation requires a Medical Necessity Form completed in accordance with 130 CMR 407.421(D). (D) Recordkeeping Requirement. Providers of ambulance services must keep records of all services billed to the MassHealth agency. Such records must be maintained in accordance with 130 CMR 450.205: Recordkeeping and Disclosure and must include a log or trip sheet, separate from the claim form, containing the vehicle number, the time of the trip, the driver's name, the name of the member transported, the date of service, the origin and destination of the trip, and the nature of the ambulance service provided. For emergency trips, the nature of the emergency must be recorded in detail, including referring source. If two or more persons are transported together, the provider must record the name of all passengers on the log or trip sheet. For specialty care transport, such records must include the appropriate paramedic level credentials of the ambulance staff or, if originating facility staff is on the vehicle, then such records must include staff names, titles, and signatures. (E) Rates of Payment. (1) Payment for ambulance services is made in accordance with 101 CMR 327.00: Rates of Payment for Ambulance and Wheelchair Van Services. (2) An ambulance trip may be considered to be a round trip if the waiting time exceeds one hour. Payment for such trips is double the base fee, plus mileage per loaded mile after 20 miles each way. (3) When two patients are transported in the same vehicle, payment for the MassHealth member is one-half the base fee. In such instances, the mileage fee applies only once. (4) The MassHealth agency does not pay for additional or supplemental fees for oxygen service, for a nurse or extra attendant, or for waiting time. (5) The service codes that must be used when billing for ambulance services are listed in Subchapter 6 of the Transportation Manual. (130 CMR 407.482 through 407.490 Reserved.)