Agenda - 06-15-2021; 8-r - Medicaid Transformation - Public Ambulance Providers (PAPs) Contracts with Public Healthcare Providers (PHPs)-Managed Care Organizations (MCOs)

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6 NC Medicaid Medicaid and Health Choice Ambulance Services Clinical Coverage Policy No: 15 Effective Date: January 15, 2020 3.2.3.1 Origin and Destination......................................................................................... 10 4.0 When the Procedure, Product, or Service Is Not Covered.............................................................11 4.1 General Criteria Not Covered...........................................................................................11 4.2 Specific Criteria Not Covered...........................................................................................11 4.2.1 Specific Criteria Not Covered by both Medicaid and NCHC..............................11 4.2.1.1 Nearest Appropriate Facility................................................................................11 4.2.1.2 Transport of Deceased Beneficiaries...................................................................11 4.2.1.3 Air Medical Ambulance.......................................................................................11 4.2.1.4 Other Non-covered Ambulance Services.............................................................11 4.2.2 Medicaid Additional Criteria Not Covered..........................................................12 4.2.2.1 Maternity Transport.............................................................................................12 4.2.2.2 Nursing Facility Non-Ambulance Transportation...............................................12 4.2.3 NCHC Additional Criteria Not Covered..............................................................12 5.0 Requirements for and Limitations on Coverage............................................................................12 5.1 Prior Approval..................................................................................................................13 5.2 Prior Approval Requirements...........................................................................................13 5.2.1 General.................................................................................................................13 5.2.2 Specific................................................................................................................13 5.3 Limitations or Requirements.............................................................................................14 6.0 Provider(s)Eligible to Bill for the Procedure,Product,or Service ...............................................14 6.1 Provider Qualifications and Occupational Licensing Entity Regulations.........................14 6.2 Provider Certifications......................................................................................................14 6.3 Licensure and Vehicles.....................................................................................................14 6.4 In-State Ambulance Service Requirements......................................................................14 6.5 Out-of-State Ambulance Service Requirements...............................................................14 7.0 Additional Requirements...............................................................................................................15 7.1 Compliance.......................................................................................................................15 7.2 Call Reports......................................................................................................................15 7.3 Physician Certification and Order for Non-Emergency Medicaid Ambulance Services..16 7.3.1 Non-Emergency, Scheduled,Repetitive Ambulance Services............................16 7.3.2 Non-Emergency Ambulance Services That Are Either Unscheduled or That Are Scheduled on a Non-Repetitive Basis..................................................................16 8.0 Policy Implementation and History...............................................................................................17 Attachment A: Claims-Related Information...............................................................................................18 A. Claim Type .......................................................................................................................18 B. International Classification of Diseases and Related Health Problems,Tenth Revisions, Clinical Modification(ICD-IO-CM) and Procedural Coding System(PCS) ...................18 C. Code(s)..............................................................................................................................18 D. Modifiers...........................................................................................................................19 E. Billing Units......................................................................................................................20 F. Place of Service................................................................................................................20 G. Co-payments.....................................................................................................................20 H. Reimbursement.................................................................................................................20 20A13 ii