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13 <br /> NC Medicaid Medicaid and Health Choice <br /> Ambulance Services Clinical Coverage Policy No: 15 <br /> Effective Date:January 15,2020 <br /> 3.2 Specific Criteria Covered <br /> 3.2.1 Specific criteria covered by both Medicaid and NCHC <br /> 3.2.1.1 Air Medical Ambulance <br /> For air medical ambulance,the point of origin is the beneficiary's <br /> loading point and runway taxiing,until the beneficiary is offloaded from <br /> the air medical ambulance. <br /> Air medical ambulance is covered in any one of the following <br /> situations: <br /> a. the beneficiary's medical condition requires immediate and rapid <br /> ambulance transport that cannot be provided by ground ambulance; <br /> b. the point of pickup is inaccessible by ground vehicle; or <br /> c. the beneficiary's condition is such that the time needed to transport <br /> the beneficiary by land, or the instability of transport by land,to <br /> the nearest appropriate facility poses a threat to the beneficiary's <br /> survival or endangers the beneficiary's health. <br /> Some conditions requiring emergency air medical ambulance <br /> transportation are: <br /> a. intracranial bleeding requiring neurosurgical intervention; <br /> b. shock; <br /> c. major burns requiring treatment in a burn center; <br /> d. conditions requiring immediate treatment in a hyperbaric oxygen <br /> unit; <br /> e. multiple severe injuries; <br /> f. life-threatening trauma; <br /> g. ST Segment Elevation Myocardial Infarction(STEMI); and <br /> h. cardiovascular Accident(CVA). <br /> 3.2.1.2 Ambulance Transport of Deceased Beneficiaries <br /> Ambulance transport of a deceased beneficiary is covered in either one <br /> of the following situations: <br /> a. The beneficiary is pronounced dead by a legally authorized <br /> individual after the dispatch of the ambulance,but before the <br /> beneficiary is loaded on board the ambulance. The provider is <br /> reimbursed for the BLS base rate.No mileage is reimbursed. The <br /> date of service is the date of the dispatch of the ambulance. Use <br /> QL modifier,"Patient pronounced dead after ambulance called," <br /> on the claim; or <br /> b. The beneficiary is pronounced dead by a legally authorized <br /> individual after pick-up but prior to arrival at the receiving facility. <br /> The same reimbursement rules apply as if the beneficiary were <br /> alive. <br /> 3.2.1.3 Out-of-State (Non-Contiguous) Transport of Beneficiaries <br /> Hospitals, acute medical care, and ambulance services are out-of-state <br /> services when they are provided more than 40 miles outside of the <br /> N.C. border. <br /> 20A 13 7 <br />