Current through Register Vol. 50, No. 6, December 1, 2023
RELATES TO:
KRS
205.520
NECESSITY, FUNCTION, AND CONFORMITY: EO 2004-726, effective
July 9, 2004, reorganized the Cabinet for Health Services and placed the
Department for Medicaid Services and the Medicaid Program under the Cabinet for
Health and Family Services. The Cabinet for Health and Family Services,
Department for Medicaid Services has responsibility to administer the Medicaid
Program.
KRS
205.520(3) authorizes the
cabinet, by administrative regulation, to comply with any requirement that may
be imposed, or opportunity presented, by federal law for the provision of
medical assistance to Kentucky's indigent citizenry. This administrative
regulation establishes the provisions relating to coverage of ambulance
transportation services to access a medical service for which payment shall be
made by the Medicaid Program.
Section
1. Definitions.
(1) "Ambulance
transportation" means ground or air transportation provided at advanced life
support level or basic life support level by a carrier licensed by the Kentucky
Board of Emergency Medical Services.
(2) "Appropriate medical facility or
provider" means a local medical provider other than an emergency room of a
hospital who can provide necessary emergency care if a hospital emergency room
is not located within the medical service area.
(3) "Attending physician" means a physician
who provided medical care to the recipient at the time ambulance transportation
was needed and may include:
(a) The physician
that the ambulance provider was in contact with to determine where the
recipient needed to be transported for immediate care;
(b) The physician at the facility that
treated the patient on arrival from the ambulance transportation;
(c) The physician at the care facility that
recommended the recipient be transported to another facility for care not
available at the original care facility; or
(d) The physician at a nursing facility that
determined that the recipient needed to be transported to a hospital.
(4) "Department" means the
Department for Medicaid Services or its designated agent.
(5) "Medical service area" means a
recipient's county of residence or a contiguous county.
(6) "Medically necessary" or "medical
necessity" means a covered benefit is determined to be needed in accordance
with
907
KAR 3:130.
(7) "Other medical professional" means a
physician assistant, advanced registered nurse practitioner, licensed nurse, or
qualified mental health professional who is approved to practice by the
appropriate professional licensure board.
Section 2. Conditions of Participation.
(1) A participating ambulance transportation
provider shall comply with the terms and conditions established in:
(a)
907
KAR 1:671, Conditions of Medicaid provider
participation; withholding overpayments, appeals process and sanctions;
and
(b)
907
KAR 1:672, Provider enrollment, disclosure and
documentation for Medicaid participation.
(2) In accordance with
907 KAR
1:005, a participating ambulance transportation
provider shall:
(a) Not bill the recipient and
the department for the same service; and
(b) Bill a third-party payer prior to billing
Medicaid for a covered service.
(3) A participating ambulance transportation
provider shall comply with the requirements regarding the confidentiality of
personal records as mandated by
42
U.S.C. 1320d and 45 C.F.R. Parts 160 and
164.
Section 3. Emergency
Ambulance Services.
(1) An emergency ambulance
service shall be covered to and from a hospital emergency room in the medical
service area if the:
(a) Service is medically
necessary; and
(b) Documentation is
maintained for postpayment review to indicate immediate emergency medical
attention was provided in the emergency room.
(2) An emergency ambulance service to an
appropriate medical facility or provider other than a hospital emergency room
shall require documentation from the attending physician of:
(a) Medical necessity;
(b) Absence of a hospital emergency room in
the medical service area; and
(c)
Delivery of emergency care to the patient.
Section 4. Nonemergency Ambulance Services.
(1) A nonemergency ambulance service to a
provider within the medical service area shall be covered if:
(a) The recipient's medical condition
warrants transport by stretcher;
(b) The recipient is traveling to or from a
Medicaid-covered service, exclusive of a pharmacy service; and
(c) The service is the least expensive
available transportation for the recipient's needs.
(2) A nonemergency ambulance service provided
outside the medical service area shall be covered if:
(a) The criteria specified in subsection (1)
of this section are satisfied;
(b)
The medical service required by the recipient is not available in the medical
service area; and
(c) The recipient
is referred by a physician.
Section 5. Documentation Required for
Determination of Coverage. The necessity for an ambulance transportation
service shall be:
(1) Determined by the
department; and
(2) Based upon a
statement of medical necessity by an attending physician which shall:
(a) Be maintained on file by the
transportation provider for a period of five (5) years; and
(b) Include the following information:
1. Verification by the provider of the:
a. Date of ambulance service;
b. Patient's name;
c. Patient's Medicaid identification
number;
d. Patient's
address;
e. Origin of ambulance
service; and
f. Destination of
ambulance service; and
2.
A signed and dated statement by the attending physician, or other medical
professional carrying out the orders of the attending physician, which verifies
the patient's diagnosis and whether or not the patient:
a. Received treatment in an outpatient
setting following transport;
b.
Required admission to the hospital following transport;
c. Transferred from one (1) medical facility
to another;
d. Was confined to bed
before and after transport;
e.
Required movement by stretcher; or
f. Had a medical condition which
contraindicated transportation by means other than an
ambulance.
Section 6. Appeal Rights.
(1) An appeal of a department decision
regarding a Medicaid recipient based upon an application of this administrative
regulation shall be in accordance with
907
KAR 1:563.
(2) An appeal of a department decision
regarding Medicaid eligibility of an individual shall be in accordance with
907
KAR 1:560.
(3) An appeal of a department decision
regarding a Medicaid provider based upon an application of this administrative
regulation shall be in accordance with
907
KAR 1:671.
2 Ky.R. 112; eff.
9-10-1975; Recodified from 904 KAR 1:060, 5-2-1986; 17 Ky.R. 1879; eff.
12-18-1990; 22 Ky.R. 2497; eff. 8-21-1996; 26 Ky.R. 658; 1184; 1421; eff.
1-12-2000; 30 Ky.R. 450; 878; eff. 10-31-2003; Crt eff.
11-26-2019.
STATUTORY AUTHORITY:
KRS
194A.030(2),
194A.050(1),
205.520(3),
42 C.F.R.
431.53,
440.170,
42
U.S.C. 1396d, EO
2004-726
