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17 <br /> NC Medicaid Medicaid and Health Choice <br /> Ambulance Services Clinical Coverage Policy No: 15 <br /> Effective Date:January 15,2020 <br /> g. Emergency transport to a behavioral health clinic or other <br /> appropriate location during a behavioral health crisis. <br /> 4.0 When the Procedure, Product, or Service Is Not Covered <br /> Note:Refer to Subsection 2.2.1 regarding EPSDT Exception to Policy Limitations for a <br /> Medicaid Beneficiary under 21 Years of Age. <br /> 4.1 General Criteria Not Covered <br /> Medicaid and NCHC shall not cover procedures,products, and services related to this <br /> policy when: <br /> a. the beneficiary does not meet the eligibility requirements listed in Section 2.0; <br /> b. the beneficiary does not meet the criteria listed in Section 3.0; <br /> c. the procedure,product, or service duplicates another provider's procedure,product, <br /> or service; or <br /> d. the procedure,product, or service is experimental, investigational, or part of a clinical <br /> trial. <br /> 4.2 Specific Criteria Not Covered <br /> 4.2.1 Specific Criteria Not Covered by both Medicaid and NCHC <br /> Medicaid and NCHC shall not cover the following: <br /> 4.2.1.1 Nearest Appropriate Facility <br /> a. The beneficiary is to be transferred to the nearest appropriate <br /> facility. Loaded mileage to a facility that does not meet this <br /> criterion is not reimbursed. <br /> b. The fact that a physician does or does not have staff privileges in a <br /> hospital is not a consideration in determining whether the hospital <br /> has appropriate facilities. <br /> c. A facility is not deemed appropriate or inappropriate based on a <br /> beneficiary's preference. <br /> 4.2.1.2 Transport of Deceased Beneficiaries <br /> Ambulance transport of a deceased beneficiary is not covered if the <br /> beneficiary is pronounced dead by a legally authorized individual <br /> before the ambulance is called. <br /> 4.2.1.3 Air Medical Ambulance <br /> Air medical ambulance transport to a facility that is not an acute-care <br /> hospital is not a covered service. <br /> 4.2.1.4 Other Non-covered Ambulance Services <br /> a. An ambulance is called and no treatment is needed. <br /> b. The ambulance responds to a false alarm call. <br /> c. The beneficiary refuses all medical services. <br /> d. Ambulance transport is for a medical service that is not a Medicaid <br /> or NCHC covered service. <br /> e. Commercial airline tickets are not reimbursable <br /> f. Airstrip fees are not covered. <br /> g. Charges for taxes(local, state, federal, etc.)are not covered. <br /> 20A13 11 <br />