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26 <br /> NC Medicaid Medicaid and Health Choice <br /> Ambulance Services Clinical Coverage Policy No: 15 <br /> Effective Date:January 15,2020 <br /> Providers must report QL modifier if the time of death pronouncement is made after dispatch but <br /> before the beneficiary is loaded onboard the ambulance. <br /> E. Billing Units <br /> Provider(s) shall report the appropriate code(s)used which determines the billing unit(s). <br /> The time of pick-up, in the range of 00-23 hours,is required on the claim form. <br /> When multiple units respond to a call for services,the provider that transports the beneficiary is <br /> the only provider that may bill for the service. If both ground and air medical ambulances are <br /> involved,then each submits its own claim and each claim is processed and reimbursed <br /> independently of the other. <br /> F. Place of Service <br /> Ambulance <br /> G. Co-payments <br /> For Medicaid refer to Medicaid State Plan: <br /> https:Hmedicaid.ncdhhs.gov/get-involved/nc-health-choice-state-plan <br /> For NCHC refer to NCHC State Plan: <br /> https:Hmedicai d.ncdhhs.gov/get-involved/nc-health-choice-state-plan <br /> H. Reimbursement <br /> Provider(s) shall bill their usual and customary charges. <br /> For a schedule of rates,refer to: https://medicaid.ncdhhs.gov/ <br /> Reimbursement is based on the level of service rendered,not the type of vehicle. The level of <br /> service is determined by medical necessity and qualifying criteria. <br /> Reimbursement includes both the transport of the Medicaid or NCHC beneficiary to the nearest <br /> appropriate facility and all supplies (disposable and nondisposable,including oxygen)associated <br /> with such transport. <br /> Reimbursement is allowed for a round trip only if the ambulance remained in the vicinity of the <br /> destination, did not return to base, and did not respond to other calls for transport. Otherwise,the <br /> provider should bill for two one-way trips. Medicaid and NCHC providers shall not bill for <br /> additional reimbursement for waiting time on round trips. Waiting time is included in the round- <br /> trip reimbursement.Medicaid and NCHC providers shall not bill a beneficiary for waiting time on <br /> round trips. <br /> If a beneficiary is transported and returned to the point of pick-up or other delivery point by a <br /> different provider on the same date of service, each provider is allowed a one-way trip. The level <br /> of reimbursement is determined by medical necessity and qualifying criteria. <br /> Ambulance transport of a Medicaid or NCHC hospice beneficiary for any service related to the <br /> terminal illness is the responsibility of the hospice provider. The ambulance provider shall contact <br /> the hospice provider prior to transport to arrange for payment. The ambulance provider shall not <br /> bill Medicaid or NCHC. <br /> 20A13 20 <br />