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5 <br /> NC Medicaid Medicaid and Health Choice <br /> Ambulance Services Clinical Coverage Policy No: 15 <br /> Effective Date: January 15, 2020 <br /> To all beneficiaries enrolled in a Prepaid Health Plan (PHP): for questions about benefits and <br /> services available on or after implementation,please contact your PHP. <br /> Table of Contents <br /> 1.0 Description of the Procedure,Product, or Service...........................................................................l <br /> 1.1 Definitions.......................................................................................................................... 1 <br /> 1.1.1 Ground and Air Medical Ambulances................................................................... 1 <br /> 1.1.2 Emergency Services............................................................................................... 1 <br /> 1.1.2.1 Emergency Medical Condition..............................................................................1 <br /> 1.1.2.2 Emergency and Immediate Responses...................................................................l <br /> 1.1.2.3 Emergency Ground Transport...............................................................................2 <br /> 1.1.2.4 Basic Life Support.................................................................................................2 <br /> 1.1.2.5 Advanced Life Support..........................................................................................2 <br /> 1.1.3 Non-emergency Medically Necessary Ambulance Transport...............................3 <br /> 1.1.4 Air Medical Ambulance.........................................................................................3 <br /> 1.1.5 Loaded Mileage.....................................................................................................3 <br /> 1.1.6 Locality..................................................................................................................4 <br /> 1.1.7 Nearest Appropriate Facility..................................................................................4 <br /> 1.1.8 Round Trip and One-Way Trip..............................................................................4 <br /> 1.1.9 Date of Service.......................................................................................................4 <br /> 1.1.10 Point of Pick-up.....................................................................................................4 <br /> 2.0 Eligibility Requirements..................................................................................................................4 <br /> 2.1 Provisions............................................................................................................................4 <br /> 2.1.1 General...................................................................................................................4 <br /> 2.1.2 Specific..................................................................................................................5 <br /> 2.2 Special Provisions...............................................................................................................5 <br /> 2.2.1 EPSDT Special Provision: Exception to Policy Limitations for a Medicaid <br /> Beneficiary under 21 Years of Age.......................................................................5 <br /> 2.2.2 EPSDT does not apply to NCHC beneficiaries.....................................................6 <br /> 2.2.3 Health Choice Special Provision for a Health Choice Beneficiary age 6 through <br /> 18 years of age.......................................................................................................6 <br /> 3.0 When the Procedure,Product, or Service Is Covered......................................................................6 <br /> 3.1 General Criteria Covered....................................................................................................6 <br /> 3.2 Specific Criteria Covered....................................................................................................7 <br /> 3.2.1 Specific criteria covered by both Medicaid and NCHC........................................7 <br /> 3.2.1.1 Air Medical Ambulance.........................................................................................7 <br /> 3.2.1.2 Ambulance Transport of Deceased Beneficiaries..................................................7 <br /> 3.2.1.3 Out-of-State(Non-Contiguous)Transport of Beneficiaries..................................7 <br /> 3.2.1.4 Out-of-County Transport of Beneficiaries.............................................................8 <br /> 3.2.1.5 Transport to Behavioral Health Crisis Centers......................................................8 <br /> 3.2.2 Medicaid Additional Criteria Covered...................................................................8 <br /> 3.2.2.1 Origin and Destination...........................................................................................8 <br /> 3.2.2.2 Non-emergency Medically Necessary Ambulance Transport...............................9 <br /> 3.2.2.3 Ambulance Services during Pregnancy...............................................................10 <br /> 3.2.3 NCHC Additional Criteria Covered....................................................................10 <br /> 20A 13 i <br />