Emergency Ambulance Program

PURPOSE: This rule establishes the regulatory basis for the admin istration of the emergency ambulance program. This rule provides for such methods and procedures relating to the utilization of, and the payment for, care and services available under the MO HealthNet program as may be necessary to safeguard against un necessary utilization of such care and services and to assure that payments are consistent with efficiency, economy, and quality of care and are sufficient to enlist enough providers so that care and services are available under the plan at least to the extent that such care and services are available to the general population in the geographic area. Specific details of provider participation, criteria and methodology for provider reimbursement, participant eligibility, and amount, duration and scope of services covered are included in the ambulance program manual, which is incorpo rated by reference in this rule and available at the website. PUBLISHER’S NOTE: The secretary of state has determined that the publication of the entire text of the material which is incorporated by reference as a portion of this rule would be unduly cumber some or expensive. This material as incorporated by reference in this rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no more than the actual cost of reproduction. This note applies only to the reference material. The entire text of the rule is printed here. (1) Administration. The MO HealthNet ambulance program shall be administered by the Department of Social Services, MO HealthNet Division. The ambulance program services covered and not covered, the limitations under which services are cov ered, and the maximum allowable fees for all covered services shall be determined by the MO HealthNet Division and shall be included in the ambulance program provider manual, which is incorporated by reference and made part of this rule as published by the Department of Social Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109, at its website at www.dss.mo.gov/mhd, May 15, 2019. This rule does not incorporate any subsequent amendments or additions. (2) Eligible Providers. To be eligible for participation in MO HealthNet, the following requirements shall be met: (A) Ground Ambulance. 1. The provider must be licensed by the Missouri Department of Health and Senior Services if located in Missouri or licensed by the state regulating authority if located outside the state of Missouri. 2. The provider must be certified to participate in the Title XVIII Medicare program and have a signed and ac cepted Participation Agreement in effect with the Missouri Department of Social Services, MO HealthNet Division; and (B) Air Ambulance. Air ambulance is defined as any privately or publicly owned conventional air service, rotary wing or fixed-wing specially designed, constructed or modified, main tained or equipped with the intent to be used for the transpor tation of patients as defined in Federal Aviation Regulations, Part 135. 1. The air ambulance provider must have a current valid air ambulance license, be licensed by the state regulating au thority if located outside of Missouri, have submitted a copy of the current Federal Aviation Regulations, Part 135, (FAA) Air Carrier Certificate issued by the United States Department of Transportation. 2. The air ambulance provider must have a signed and accepted Participation Agreement for the air ambulance pro gram in effect with the Missouri Department of Social Services, MO HealthNet Division. (3) Participant Eligibility. The ambulance provider must ascer tain the patient’s MO HealthNet status before billing for ser vices. The participant’s MO HealthNet/Managed Care eligibility is determined by the Family Support Division. The participant must be eligible for MO HealthNet on the date that a service is provided in order for a provider to receive MO HealthNet reimbursement. It is the provider’s responsibility to determine the coverage benefits for a participant based on their type of assistance as outlined in the ambulance program manual. The participant’s eligibility shall be verified in accordance with methodology outlined in the ambulance program manual. (4) Prior Authorization. Emergency ambulance services do not require prior authorization. All non-emergency, MO HealthNet covered services that are to be performed or furnished out-ofstate for eligible MO HealthNet participants and for which MO HealthNet is to be billed, must be prior authorized before the out-of-state services are provided. A prior authorization is not required for out-of-state emergency services. (5) Services Covered and Service Limitations. The MO HealthNet ambulance manual shall provide the detailed listing of pro cedure codes and pricing information covered by the MO HealthNet ambulance program. (A) Covered ambulance services are— 1. Transportation is made to the nearest appropriate hos pital when the criteria for emergency services is met (see (5) (B) below); 2. On-site treatment provided by an emergency medical technician or by a paramedic that meets the following criteria: A. The treatment is a result of an emergent or immedi ate response made by a licensed ambulance service; B. The emergency medical technician (EMT) or para medic provides an assessment to determine the MO HealthNet participant’s medical condition; C. Medically necessary treatment is provided to the par ticipant on-site; and D. The participant is not transported by the responding service provider to an emergency department; and 3. On-site referral for further treatment that meets the following criteria: A. The referral is a result of an emergent or immediate response made by a licensed ambulance services; B. The EMT or paramedic provides an assessment to determine the MO HealthNet participant’s medical condition; C. The referral is provided to the participant; and D. The participant is not transported by the responding service provider to an emergency department. (B) Emergency services are services required when there is a sudden or unforeseen situation or occurrence or a sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that the absence of immediate medical attention could reasonably be expected to result in placing the patient’s health in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part. Nearest appropriate hospital is the hospital that is equipped and staffed to provide the needed care for the illness or injury involved. MO HealthNet does not allow transportation to a more distant hospital solely to avail a patient of the services of a specific physician or family or personal preference when considering the nearest appropriate facility. (C) Exceptions to Emergency Services. 1. MO HealthNet covers medically necessary ambulance services for participants under twenty-one (21) years of age through the Healthy Children and Youth (EPSDT/HCY) program. The Omnibus Budget Reconciliation Act of 1989 (OBRA 89) expanded medically necessary services for children under the age of twenty-one (21) through the Early Periodic Screening, Diagnosis and Treatment (EPSDT) program, also known as the Healthy Children and Youth (HCY) program. This allows for non-emergency transportation of children by ambulance for health care when other modes of travel are not medically appropriate and may endanger the child’s health. When other modes of transportation are available that would allow for safe transport of the child, these options must be utilized. 2. Transportation to and from one hospital to another and return for specialized testing and/or treatment is covered. 3. MO HealthNet covers transportation from the point of pickup to two (2) different hospitals made on the same day by the same ambulance provider when it is medically necessary. 4. Ground ambulance transfers of patients from one hospi tal to another hospital to receive medically necessary inpatient services not available at the first facility shall be covered by MO HealthNet. Hospital transfers shall be covered when the patient has been stabilized at the first hospital, but needs a higher level of care available only at the second hospital. (D) MO HealthNet covers emergency rotary wing air ambu lance only when: 1. Transportation by ground ambulance is contraindi cated; or 2. The patient’s medical condition is such that immediate and rapid ambulance transportation is essential and cannot be provided by ground ambulance; or 3. Great distances or other obstacles are involved in get ting the patient to the nearest hospital with appropriate facil ities; or 4. The patient’s medical condition is such that the time needed to transport by land, or the instability of transportation by land poses a threat to the patient’s survival or seriously en dangers the patient’s health; or 5. The point of pickup is inaccessible by land vehicle; and 6. All other MO HealthNet requirements for coverage are met. (E) MO HealthNet covers fixed-wing air ambulance when: 1. The weather situation at the time of transport prohibits the use of a rotary wing ambulance; or 2. Transportation by ground ambulance or rotary wing ambulance is contraindicated; or 3. The patient’s medical condition is such that immediate and rapid ambulance transportation is essential and cannot be provided by ground ambulance or rotary wing ambulance; or 4. Great distances or other obstacles are involved in getting the patient to the nearest hospital with appropriate facilities; or 5. The patient’s medical condition is such that the time needed to transport by land or rotary wing, or the instability of transportation by land or rotary wing ambulance poses a threat to the patient’s survival or seriously endangers the pa tient’s health; or 6. The point of pickup is inaccessible by land vehicle; and 7. All other MO HealthNet requirements for coverage are met. (6) Services Not Covered. (A) Ground Ambulance. The following services are not cov ered under the ground ambulance program: 1. Ambulance transportation to a physician’s office, a dentist’s office, a nursing home, or a patient’s home except for participants under twenty-one (21) (except ME codes 76-79) through the EPSDT/HCY program; 2. Ambulance services to a hospital for the first stage of labor; 3. Non-emergency ambulance trips are not covered with the exceptions of those services listed above; 4. If a participant is pronounced dead before the ambu lance is called, no MO HealthNet payment is made; or 5. Ancillary services and supplies are not covered when the patient is not transported. (B) Air Ambulance. The following services are not covered under the air ambulance program: 1. Air ambulance trip for the patient’s personal preference; 2. Patient not transported to the nearest hospital with ap propriate facilities; 3. Ambulance trips ordered by the Veteran’s Administration Hospital; 4. Transport of medical team (or other medical profession als) to meet a patient; 5. Ground mileage; 6. Transport to a facility that is not an acute care hospi tal, such as a nursing facility or physician’s office or dentist’s office or independent clinic or independent laboratory or to a patient’s home; 7. Transport if a participant is pronounced dead before the air ambulance is called; or 8. Ancillary services and supplies when the patient is not transported. (C) When individuals are transported by ambulance to an emergency room and are subsequently treated and released without admission to the hospital, the return trip is not cov ered under the emergency ambulance program. (7) General Regulations. General regulations of the MO HealthNet program apply to the ambulance program. (8) Reimbursement. Payment will be made in accordance with the fee per unit of service as defined and determined by the MO HealthNet Division. Providers must bill their usual and customary charge for ambulance services. Reimbursement will not exceed the lesser of the maximum allowed or the provid er’s billed charges. Ambulance program services are only pay able to the enrolled, eligible, participating provider. The MO HealthNet program cannot reimburse for services performed by non-enrolled providers. (9) Other Source Payment. The MO HealthNet payment for am bulance services cannot duplicate or replace benefits available to the participant from any other source, public or private. A settlement received from private insurance or litigation as the result of an accident must be used toward payment of the am bulance bill. MO HealthNet shall be the last source of payment on any claim. Any payment received from a private insurance carrier or other acceptable source shall be listed on the claim form. If the settlement received is equal to or exceeds the fee that could be allowed by MO HealthNet, no payment shall be made by MO HealthNet. (10) Documentation Requirements for Emergency Ambulance Program. All services must be adequately documented in the medical record. Adequate documentation means doc umentation from which services rendered and the amount of reimbursement received by a provider can be readily dis cerned and verified with reasonable certainty. Documentation includes the Missouri Ambulance Reporting Form (trip ticket). In addition to the above documentation requirements, each licensee of an air ambulance must maintain accurate records that contain information concerning the air transportation of each patient. The patient record shall be maintained and shall accurately document the patient care rendered by the medical flight crew and the disposition of the patient at the receiving facility. The documentation of the emergency air ambulance flight record (trip ticket) must contain a description of the pa tient’s medical condition with sufficient detail to demonstrate the need for emergency air ambulance. (11) Records Retention. The enrolled MO HealthNet ambulance provider shall keep any records necessary to fully document compliance with this regulation and the services the provider furnishes to participants. These records must be retained for seven (7) years from the date of service. Fiscal and medical records must coincide with and fully document services billed to the MO HealthNet agency. Providers must furnish or make the records available for inspection or audit by the Department of Social Services or its representative upon request. Failure to furnish, reveal or retain adequate documentation for services billed to the MO HealthNet program, as specified above, is a violation of this regulation. AUTHORITY: sections 208.201 and 660.017, RSMo 2016, and sec tion 208.152, RSMo Supp. 2019.* Original rule filed Feb. 10, 2006, effective Sept. 30, 2006. Amended: Filed Aug. 1, 2006, effective Feb. 28, 2007. Amended: Filed Aug. 23, 2007, effective March 30, 2008. Amended: Filed July 31, 2008, effective Feb. 28, 2009. Amended: Filed May 15, 2019, effective Dec. 30, 2019. *Original authority: 208.152, RSMo 1967, amended 1969, 1971, 1972, 1973, 1975, 1977, 1978, 1978, 1981, 1986, 1988, 1990, 1992, 1993, 2004, 2005, 2007, 2011, 2013, 2014, 2015, 2016, 2018; 208.201, RSMo 1987, amended 2007; and 660.017, RSMo 1993, amended 1995.