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19 <br /> NC Medicaid Medicaid and Health Choice <br /> Ambulance Services Clinical Coverage Policy No: 15 <br /> Effective Date:January 15,2020 <br /> 5.1 Prior Approval <br /> Prior approval(PA) is required for non-emergency ambulance services for a Medicaid <br /> beneficiary by ground or air from North Carolina to another state, from one state to <br /> another, or from another state back to North Carolina. Medical necessity determination is <br /> based on the documentation submitted by the provider. PA must be obtained before <br /> rendering out-of-state non-emergency ambulance services. PA for ambulance service is <br /> separate from PA for a medical procedure or treatment provided out of state. <br /> Obtaining PA does not guarantee payment, ensure beneficiary eligibility on the date of <br /> service, or guarantee a post-payment review to verify that the service was appropriate and <br /> medically necessary will not be conducted. A beneficiary must be eligible for Medicaid <br /> coverage on the date the procedure is performed or the service rendered. In accordance <br /> with l0A NCAC 22J.0106 (d),the provider cannot bill beneficiaries when he fails to <br /> follow program regulations or when the claim denies on the basis of a lack of medical <br /> necessity. <br /> A provider requesting PA for state-to-state ambulance transport shall submit both the <br /> State-to-State Ambulance Transportation Addendum(Form 372-118A) and the Medicaid <br /> Prior Approval Form(Form 372-118)to NC Medicaid's designee. The request may be <br /> made by the transferring facility or the receiving facility. Forms are available at <br /> https://medicaid.ncdhhs.gov/. <br /> NCHC does not cover non-emergency medical transportation. <br /> Services must be provided in compliance with all applicable rules,regulations,laws, and <br /> current standards of practice. When requesting authorization for payment of services,the <br /> provider shall submit the beneficiary's face sheet and any other relevant information that <br /> demonstrates the beneficiary had an emergency medical condition as defined in 42 C.F.R. <br /> 489.24(c)(3). <br /> PA is not required for in-state emergency ambulance services, ground or air,for <br /> Medicaid or NCHC beneficiaries. <br /> 5.2 Prior Approval Requirements <br /> 5.2.1 General <br /> The provider(s) shall submit to the Department of Health and Human Services <br /> (DHHS)Utilization Review Contractor the following: <br /> a. the prior approval request; and <br /> b. all health records and any other records that support the beneficiary has met <br /> the specific criteria in Subsection 3.2 of this policy. <br /> 5.2.2 Specific <br /> a. Each trip requires a separate PA process and PA number <br /> b. For non-emergency medically necessary ambulance transport,PA shall be <br /> obtained before service is rendered for a Medicaid beneficiary. <br /> c. The PA is active for 30 calendar days. <br /> 20A13 13 <br />