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Ambulance Transport Reimbursement Guidelines for Commercial and State PPO Benefit plans

Please be advised this policy has been revised and replaces any other versions previously released.

Blue Cross and Blue Shield of North Carolina (BCBSNC) is committed to providing timely notification of reimbursement changes.

BCBSNC has historically reimbursed for non-emergency ambulance transports and is currently seeking refunds for those services. As of July 1, 2011, all non-emergency transports will deny as a non-covered service and eliminate the need for retrospective refund requests.

Policy: All Commercial and State PPO Benefit plans will cover services in a ground ambulance traveling:

  • From a member's home or scene of an accident or emergency to a hospital
  • Between hospitals
  • Between a hospital and a skilled nursing facility when such a facility is the closest one that can provide covered services appropriate to the member's condition,
  • To and from a dialysis facility for Medicare Primary ESRD members who require dialysis, and
  • A physician's office is not a covered destination. However, under special circumstances an ambulance transport may temporarily stop at a physician's office without affecting the coverage status of the transport.

Benefit plans also cover services in an air ambulance traveling from the site of an emergency to a hospital when such a facility is the closest one that can provide covered services appropriate to the member's condition and ground transportation is not medically appropriate due to the severity of the illness or the pick-up point is inaccessible by land.

Benefits may also be provided for ambulance services from a hospital or skilled nursing facility to a member's home when medically necessary.

If the non-emergency ground ambulance service is not medically necessary, members may be responsible for charges. No benefits are provided primarily for the convenience of travel.

Billing Recommendations: For the most efficient handling of ambulance transport claims, BCBSNC recommends the following billing practices for its commercial lines of business:

  • All ambulance transport codes and mileage codes must be reported with both the corresponding origin and destination modifiers.
  • Origin and destination modifiers must be listed in the first modifier field on all service lines of the claim.
  • For medical necessity review of non-emergency transport, a completed trip sheet in a legible format, expedites the review process.
  • For Medicare Primary ESRD members transported to and from a dialysis center, ESRD must be the primary diagnosis on all service lines of the claim.

BCBSNC's Medical Policy entitled Ambulance and Medical Transport Services is available at: http://www.bcbsnc.com/assets/services/public/pdfs/medicalpolicy/ambulance_and_medical_transport_services.pdf

These changes are applicable for BCBSNC commercial and State Health Plan PPO benefit plans.