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8 <br /> NC Medicaid Medicaid and Health Choice <br /> Ambulance Services Clinical Coverage Policy No: 15 <br /> Effective Date:January 15,2020 <br /> 1.1.2.3 Emergency Ground Transport <br /> Emergency ground transport is medically necessary ground <br /> transportation to the nearest appropriate facility where prompt medical <br /> services are provided in an emergency situation such as accident, acute <br /> illness, or injury. Emergency ground transport includes both BLS and <br /> ALS services. <br /> 1.1.2.4 Basic Life Support <br /> BLS is transportation by a ground ambulance vehicle and the provision <br /> of medically necessary supplies and services,including BLS <br /> ambulance services as defined by the State Office of Emergency <br /> Medical Services(GEMS). The ambulance shall be staffed by an <br /> individual who is credentialed in accordance with 1O NCAC 13P <br /> .0502 and G.S. 131E-159 as an Emergency Medical Technician <br /> (EMT). <br /> 1.1.2.5 Advanced Life Support <br /> ALS services include BLS plus invasive procedures and techniques <br /> provided by Emergency Medical Technicians—Intermediate(EMT-1) <br /> or Emergency Medical Technicians—Paramedic (EMT—P)who are <br /> credentialed in accordance with l0A NCAC 13P .0502. An EMT—I is <br /> credentialed to perform essential advanced techniques and to <br /> administer a limited number of medications in addition to the skills of <br /> the EMT. An EMT—P is credentialed to administer additional <br /> medications and interventions in addition to the skills of the EMT and <br /> EMT-I. <br /> An ALS assessment must be a medically necessary procedure <br /> performed by an ALS crew as part of an emergency response and <br /> necessary because the beneficiary's reported condition at the time of <br /> dispatch is such that only an ALS crew is qualified to perform the <br /> assessment.An ALS assessment does not necessarily result in a <br /> determination that the beneficiary requires an ALS level of service. <br /> An ALS intervention is a procedure that is,in accordance with state <br /> and local laws,rendered by ALS personnel. If local protocols require <br /> an ALS response for all calls,N.C. Medicaid only covers the level of <br /> service actually provided.ALS level of service must include ALS <br /> assessment,ALS intervention, or both,and then only when the service <br /> is medically necessary. <br /> ALS Level 1 (ALS 1) is the transportation by ground ambulance <br /> vehicle and the provision of an ALS assessment or at least one ALS <br /> intervention. <br /> ALS Level 2 (ALS2) is the transportation by ground ambulance <br /> vehicle and the provision of medically necessary supplies and services, <br /> including at least one of the following: <br /> a. At least three separate administrations of one or more medications <br /> by intravenous push or bolus or by continuous infusion, excluding <br /> 20A 13 2 <br />