Louisiana Administrative Code
Title 40 - LABOR AND EMPLOYMENT
Part I - Workers' Compensation Administration
Subpart 2 - Medical Guidelines
Chapter 39 - Medical Transportation Reimbursement Schedule, Billing Instructions, and Maintenance Procedures
Section I-3911 - Schedule of Maximum Allowances
Current through Register Vol. 50, No. 9, September 20, 2024
A. This document provides the basis for identification of procedures to be reimbursed to transportation vendors. The coding source is the health care financing administration common procedure coding system (HCPCS). No other coding methodology will be accepted by the carrier/self-insured employer. Please do not bill using any of the modifiers. Modifiers will not affect payment and may cause your bill to be unnecessarily delayed.
B. This fee schedule provides the basis for reimbursement of medical transportation. Reimbursement is limited to the least of:
|
State of Louisiana Office of Workers' Compensation Schedule of Maximum Allowances for Medical Transportation |
||
|
HCPCS |
Description |
Maximum Allowable |
|
A0140 |
Nonemergency Transportation and Air Travel (Private or Commercial), Intra or Interstate |
B.R. |
|
A0999 |
Unlisted Ambulance Service |
B.R. |
|
A0380 |
Emergency Ambulance Service, BLS per Mile, One Way |
$6 |
|
A0390 |
Emergency Ambulance Service, (ALS) Per Mile, One Way |
$7 |
|
A0420 |
Ambulance Service, Waiting Time, One Half (1/2) Hour Increments, Rate per Unit (See Table Below) |
$42 |
|
A0422 |
Ambulance Service, Oxygen, Administration and Supplies, Life Sustaining Situation |
B.R. |
|
A0427 |
Emergency Ambulance Service, Advanced Life Support (ALS) Base Rate, All Inclusive Services, One Way |
$375 |
|
A0428 |
Nonemergency Transportation, Ambulance, Base Rate, One Way |
$169 |
|
A0429 |
Emergency Ambulance Service, BLS Rate One Way |
$258 |
|
A0430 |
Ambulance Service, Conventional Air Service One Way |
B.R. |
|
A0431 |
Ambulance Service, Air, Helicopter, v |
B.R. |
AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1034.2.
