Orange County NC Website
Browse       Search
21 <br /> NC Medicaid Medicaid and Health Choice <br /> Ambulance Services Clinical Coverage Policy No: 15 <br /> Effective Date:January 15,2020 <br /> c. An enrolled Medicare ambulance provider; and <br /> d. Enrolled with an N.C. Medicaid provider number. <br /> 7.0 Additional Requirements <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 /> 7.1 Compliance <br /> Provider(s) shall comply with the following in effect at the time the service is rendered: <br /> a. All applicable agreements, federal, state and local laws and regulations including the <br /> Health Insurance Portability and Accountability Act(HIPAA) and record retention <br /> requirements; and <br /> b. All NC Medicaid's clinical(medical)coverage policies,guidelines,policies,provider <br /> manuals, implementation updates, and bulletins published by the Centers for <br /> Medicare and Medicaid Services(CMS),DHHS,its divisions or its fiscal agent. <br /> 7.2 Call Reports <br /> The ambulance provider shall maintain all call reports,PA forms, documentation to <br /> support the miles billed, and any other records prepared or received in regard to the <br /> service rendered to Medicaid and NCHC beneficiaries and claimed for reimbursement. <br /> The provider shall retain the records for a minimum of six years from the date of service, <br /> unless a longer retention period is required, and shall be made available to NC Medicaid <br /> or its NC Medicaid's designee upon request. <br /> Submission of call reports is not required when filing ambulance claims. <br /> A call report shall be legible, complete, and accurate and: <br /> a. Include a complete description of the beneficiary at the scene and in transit: <br /> 1. Detail the condition necessitating the ambulance service; <br /> 2. Include a physical description of the beneficiary's position,location, and status <br /> during the initial encounter(for example, lying on the floor or sitting in a <br /> wheelchair); <br /> 3. Include data on how,when, and where the beneficiary was found; all vital signs; <br /> level of consciousness; and other relevant information; <br /> 4. Document all treatments rendered and the beneficiary's response to treatment; <br /> 5. Use sufficient detail to justify that the beneficiary's health and safety would be <br /> endangered if transported other than by stretcher; and <br /> 6. Use sufficient detail to support the medical necessity of the transport,the <br /> condition codes billed, and the level of care provided.If the ambulance service <br /> does not meet medical necessity and coverage criteria,the provider shall <br /> document this information on the call report to ensure a complete and accurate <br /> record of the beneficiary's condition. <br /> b. Include the time in the range of 00-23 hours,the point of pickup,the destination, and <br /> the number of loaded miles; <br /> c. Document that the transport is to the nearest appropriate facility; and <br /> d. Document one-way or round-trip ambulance transport. <br /> 20A13 15 <br />