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14 <br /> NC Medicaid Medicaid and Health Choice <br /> Ambulance Services Clinical Coverage Policy No: 15 <br /> Effective Date:January 15,2020 <br /> Hospitals, acute medical care, and ambulance services provided within <br /> 40 miles of the N.C. border in the contiguous states of Georgia, South <br /> Carolina,Tennessee, and Virginia will be covered to the same extent <br /> and under the same conditions as services provided in North Carolina. <br /> These facilities and providers shall obtain Medicaid provider numbers. <br /> Contact NC Medicaid Provider Services(hgps:Hmedicaid.ncdhhs.gov/) <br /> for information on obtaining a Medicaid Provider number. <br /> Refer to clinical coverage policy,2A-3, Out-of-State Services, at <br /> htt2s:Hmedicaid.ncdhhs.gov/. <br /> 3.2.1.4 Out-of-County Transport of Beneficiaries <br /> Ground ambulance loaded mileage is reimbursable only for out-of- <br /> county transport. <br /> 3.2.1.5 Transport to Behavioral Health Crisis Centers <br /> NC Medicaid shall cover transport of Medicaid beneficiaries in <br /> behavioral health crisis to behavioral health clinics or alternative <br /> appropriate care locations when the following criteria are met: <br /> a. Emergency Medical Services(EMS)providers have received <br /> appropriate education in caring for beneficiaries in behavioral health <br /> crisis; <br /> b. EMS system has at least one partnership with a receiving facility <br /> that is able to provide care appropriate for those beneficiaries; and <br /> c. EMS systems shall be required to include in its EMS system plan a <br /> report on beneficiary experiences and outcomes in accordance with <br /> rules adopted by Department of Health and Human Services <br /> (DHHS),Division of Health Service Regulation(DHSR),Division <br /> of Health Benefits(DHB), and Office of Emergency Services <br /> (GEMS) <br /> (Session Law 2018-5 Section 11H.4(a)) <br /> 3.2.2 Medicaid Additional Criteria Covered <br /> 3.2.2.1 Origin and Destination <br /> Medicaid shall cover ambulance transports(that meet all other program <br /> requirements for coverage) only to the following destinations: <br /> d. hospital; <br /> e. critical access hospital; <br /> f. skilled nursing facility; <br /> g. adult care home; <br /> h. intermediate care facility for individuals with intellectual <br /> disabilities(ICF-IID); <br /> i. beneficiary's primary private residence; <br /> j. dialysis facility for end-stage renal disease if the beneficiary's <br /> condition requires ambulance services; <br /> k. transfer site(airport or helipad); <br /> 1. physician's office; <br /> 20A 13 8 <br />