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15 <br /> NC Medicaid Medicaid and Health Choice <br /> Ambulance Services Clinical Coverage Policy No: 15 <br /> Effective Date:January 15,2020 <br /> 1. Non-emergency transport to a physician's office shall meet the <br /> criteria in Subsection 3.2.2.2,Non-Emergency Medically <br /> Necessary Ambulance Transport. <br /> 2. Emergency transportation to a physician's office shall meet the <br /> following conditions: <br /> A. the beneficiary is en route to a hospital; <br /> B. there is medical need for a professional to stabilize the <br /> beneficiary's condition; and <br /> C. the ambulance continues the trip to the hospital <br /> immediately after stabilization. <br /> in. emergency transport from hospital to hospital is appropriate when <br /> the transferring facility does not have adequate facilities to provide <br /> needed care. Coverage is available only if the beneficiary is <br /> transferred to the nearest appropriate facility such as, <br /> transportation between burn centers,neonatal care centers,trauma <br /> units,primary cardiac intervention centers, and stroke centers; and <br /> n. emergency transport of a beneficiary residing in a nursing home <br /> shall meet medical necessity criteria for an emergency, and the <br /> services needed shall be unavailable at the facility. <br /> 3.2.2.2 Non-emergency Medically Necessary Ambulance Transport <br /> Non-emergency medically necessary ambulance transport is covered <br /> for Medicaid beneficiaries only in the following situations: <br /> a. medical necessity is indicated when the use of other means of <br /> transportation is medically contraindicated. This refers to <br /> beneficiaries whose medical condition requires transport by <br /> stretcher; <br /> b. the beneficiary is in need of medical services that cannot be <br /> provided in the place of residence; or <br /> c. return transportation is provided from a facility that can provide <br /> total care for every aspect of an injury or disease to a facility that <br /> has fewer resources to offer highly specialized care. <br /> Non-emergency medically necessary ambulance transport is <br /> appropriate in either of the following situations: <br /> a. the beneficiary is bed confined and it is documented that the <br /> beneficiary's medical condition is such that a stretcher is the only <br /> safe mode of transportation; or <br /> b. the beneficiary's medical condition,regardless of bed confinement, <br /> is such that transportation by ambulance is medically required. <br /> A beneficiary is bed confined when all of the following criteria are <br /> met. The beneficiary is: <br /> a. unable to get up from bed without assistance; <br /> b. unable to ambulate; and <br /> c. unable to sit in a chair or wheelchair. <br /> A provider shall move a bed-confined beneficiary by stretcher for: <br /> 20A13 9 <br />