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20 <br /> NC Medicaid Medicaid and Health Choice <br /> Ambulance Services Clinical Coverage Policy No: 15 <br /> Effective Date:January 15,2020 <br /> 5.3 Limitations or Requirements <br /> The provider shall bill only one ambulance procedure code for the same date of service, <br /> the same hour or time of pick-up, and the same or a different provider. <br /> The provider shall not bill a round-trip ambulance transport and a one-way-trip <br /> ambulance transport on the same date of service. If this situation occurs,the provider <br /> shall submit an adjustment request with documentation that substantiates a round trip and <br /> an additional one-way trip on the same date of service. <br /> 6.0 Provider(s) Eligible to Bill for the Procedure, Product, or Service <br /> To be eligible to bill for procedures,products, and services related to this policy,the provider(s) <br /> shall: <br /> a. meet Medicaid or NCHC qualifications for participation; <br /> b. have a current and signed Department of Health and Human Services(DHHS) Provider <br /> Administrative Participation Agreement; and <br /> c. bill only for procedures,products, and services that are within the scope of their clinical <br /> practice, as defined by the appropriate licensing entity. <br /> 6.1 Provider Qualifications and Occupational Licensing Entity Regulations <br /> None Apply. <br /> 6.2 Provider Certifications <br /> None Apply. <br /> 6.3 Licensure and Vehicles <br /> Ambulance providers shall comply with licensure and credentialing requirements of the <br /> State Office of Emergency Medical Services(OEMS)in the Division of Health Service <br /> Regulation(DHSR)and G.S. 131E-155.1. The beneficiary shall be transported in an <br /> appropriately equipped vehicle that has been inspected and issued a permit by the State <br /> OEMS and the ambulance provider shall comply with G.S. 131E-156 and 131E-157. <br /> Staffing shall be in accordance with G.S. 151E-158 and l0A NCAC 13P and appropriate <br /> for the level of care provided to the Medicaid or NCHC beneficiary. The OEMS Website <br /> is located at https://www.ncdhhs.gov/divisions/dhsr. <br /> 6.4 In-State Ambulance Service Requirements <br /> In-state ambulance service providers shall meet each of the following requirements: <br /> a. Have a valid license from the State GEMS; <br /> b. Hold a current permit issued by OEMS on the vehicle(s)used for transport; <br /> c. Participate as an ambulance provider in the Medicare program; and <br /> d. Staff the ambulance in accordance with State and local laws,including staff <br /> credentialing in accordance with OEMS. <br /> 6.5 Out-of-State Ambulance Service Requirements <br /> Out-of-state ambulance service providers shall meet all of the following requirements: <br /> a. A valid license as an ambulance provider under the laws of the state in which the <br /> provider operates; <br /> b. An enrolled Medicaid ambulance provider in the state in which the provider operates; <br /> 20A13 14 <br />