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22 <br /> NC Medicaid Medicaid and Health Choice <br /> Ambulance Services Clinical Coverage Policy No: 15 <br /> Effective Date:January 15,2020 <br /> 7.3 Physician Certification and Order for Non-Emergency Medicaid Ambulance <br /> Services <br /> The ambulance provider shall obtain the signed written order and certification with the <br /> appropriate signatures before billing for the following services: <br /> 7.3.1 Non-Emergency, Scheduled,Repetitive Ambulance Services <br /> For all non-emergency, scheduled,repetitive ambulance services,ambulance <br /> providers shall obtain from the Medicaid beneficiary's attending physician a <br /> written order certifying the medical necessity of the ambulance services. The <br /> physician's order shall be dated no earlier than 60 calendar days before the date <br /> the service is furnished. <br /> 7.3.2 Non-Emergency Ambulance Services That Are Either Unscheduled or <br /> That Are Scheduled on a Non-Repetitive Basis <br /> For a Medicaid beneficiary who is under the care of a physician,the ambulance <br /> provider shall obtain a written order certifying the medical necessity from the <br /> beneficiary's attending physician within 48 hours after the transport. <br /> If the ambulance provider cannot obtain the written order and certification with <br /> appropriate signatures within 21 calendar days following the date of service,the <br /> provider shall document the attempts to obtain the requested order and <br /> certification and may then submit the claim to NC Medicaid's designee. <br /> If the ambulance provider cannot obtain a signed physician certification <br /> statement from the beneficiary's attending physician,he shall obtain a signed <br /> certification statement from either the physician assistant(PA),nurse practitioner <br /> (NP), clinical nurse specialist(CNS),registered nurse(RN), or discharge planner <br /> who has personal knowledge of the beneficiary's condition at the time the <br /> ambulance transport is ordered, or the service is furnished. <br /> This individual shall be employed by the beneficiary's attending physician or by <br /> the hospital or facility where the beneficiary is being treated and from which the <br /> beneficiary is transported. <br /> A physician order is not required for a Medicaid beneficiary who resides at home <br /> or in a facility and is not under the direct care of a physician. <br /> The presence of the signed physician certification statement does not necessarily <br /> demonstrate that the transport was medically necessary and that it met coverage <br /> criteria. The ambulance provider shall meet all coverage criteria, including call <br /> report criteria, in order for reimbursement to be made. <br /> 20A13 16 <br />