Ambulance Services Guidelines

(1) All non-emergency ground and air ambulance service provided to workers’ compensation claimants shall be pre-certified. Emergency ground and air ambulance services may be retrospectively reviewed within three (3) business days. (2) All ground and air ambulance services shall be medically necessary and appropriate. Documentation and trip sheets shall be submitted with the bill that states the condition and that indicates the necessity of the ground and air ambulance service provided. It should readily indicate the need for transport via this mode rather than another less expensive form of transportation. The service billed shall be supported by the documentation submitted for review. (3) Billing shall be submitted to the employer or carrier on a properly completed CMS-1500 form (or its successor form) by HCPCS code. Hospital based or owned providers shall submit charges on a CMS-1500 form (or its successor form) by HCPCS code. (4) Reimbursement for ground services shall be based upon the lesser of the submitted charge or the amount listed in the rate tables (based on 150% of Medicare). (5) The rates determined in the preceding sentence shall not apply to air ambulance services as defined by federal law.