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10 <br /> NC Medicaid Medicaid and Health Choice <br /> Ambulance Services Clinical Coverage Policy No: 15 <br /> Effective Date:January 15,2020 <br /> 1.1.6 Locality <br /> Locality means the service area surrounding the institution to which beneficiaries <br /> normally travel or are expected to travel to receive hospital or skilled nursing <br /> services. <br /> If two or more facilities that meet the destination requirements can treat the <br /> beneficiary appropriately, and the locality of each facility encompasses the place <br /> where the ambulance transportation of the beneficiary began,then the out of <br /> county mileage(if applicable)to any one of the facilities to which the beneficiary <br /> is taken is covered. <br /> 1.1.7 Nearest Appropriate Facility <br /> The nearest appropriate facility for emergency transport is the nearest institution <br /> or medical facility that is capable,under federal and state laws, of furnishing the <br /> required type of care for the beneficiary's illness or injury. <br /> 1.1.8 Round Trip and One-Way Trip <br /> A round trip is non-emergency transportation by ambulance from the point of <br /> pickup to destination and return to point of pickup. The ambulance remains in the <br /> vicinity of the destination, does not return to base, and does not respond to other <br /> calls for transport. This service is covered for Medicaid beneficiaries only. <br /> Refer to Subsection 4.0. <br /> A one-way trip is emergency or non-emergency transportation from point of <br /> pickup to destination. Delivery of the beneficiary at the destination discharges the <br /> ambulance provider's responsibility. The ambulance service is then available to <br /> transport other beneficiaries. <br /> 1.1.9 Date of Service <br /> The date of service of an ambulance service is the date that the loaded ambulance <br /> vehicle departs the point of pick-up. In the case of a ground transport,if the <br /> beneficiary is pronounced dead after the vehicle is dispatched but before the <br /> (now deceased)beneficiary is loaded into the vehicle,the date of service is the <br /> date of the vehicle's dispatch. <br /> 1.1.10 Point of Pick-up <br /> The point of pick-up is the location of the beneficiary at the time placed on board <br /> the ambulance. <br /> 2.0 Eligibility Requirements <br /> 2.1 Provisions <br /> 2.1.1 General <br /> (The term "General"found throughout this policy applies to all Medicaid and <br /> NCHC policies) <br /> a. An eligible beneficiary shall be enrolled in either: <br /> 1. the NC Medicaid Program; or <br /> 2. the NC Health Choice Program on the date of service and shall meet the <br /> criteria in Section 3.0 of this policy. <br /> 20A13 4 <br />