Code of Maine Rules
10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES
144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL
Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL)
Chapter II - Specific Policies By Service
Section 144-101-II-5 - AMBULANCE SERVICES
Subsection 144-101-II-5.05 - RESTRICTED SERVICES

Universal Citation: 10 ME Code Rules § 144-101-II-5.05

Current through 2024-38, September 18, 2024

5.05-1 Air Ambulance Services

A. Air ambulance services are covered services when the provider demonstrates that each of the following conditions is met:

1. For in-state air ambulance providers:

a. The attending physician certifies it is medically inadvisable for the member to travel any other way; and

b. In the case where the member is airlifted from the scene of an injury or emergency illness, aero medical transport has been determined to be necessary by EMS personnel at the scene. The medical condition must require immediate and rapid ambulance service that could not be provided by ground transportation because:

(1) the point of pick up is inaccessible by land, obstacles (i.e.: heavy traffic) or

(2) great distances are involved in getting the member to the nearest hospital with appropriate facilities.

2. For out-of-state air ambulance providers:

a. The attending physician certifies it is medically inadvisable for the member to travel any other way; and

b. Prior authorization has been obtained from MaineCare Services, Prior Authorization Unit (see Section 5.08-2). Before requesting prior authorization for air ambulance services, the provider must determine which type of transportation (i.e. fixed wing or helicopter) would be the most medically-appropriate, quickest and least expensive and provide the amount of timerequired for both types of transport in order for Prior Authorization Unit staff to determine the most medically appropriate type of service for the MaineCare member. In the case of emergency air transport, prior authorization may be granted retroactively.All guidelines set forth in Chapter I, Section 1.14-2 of the MaineCare Benefits Manual must be followed.

B. The provider shall provide the most medically appropriate and cost efficient aircraft for each case, and the aircraft must comply with all regulations for air ambulance of Maine Emergency Medical Services (MEMS), or comparable other jurisdiction. The air ambulance provider shall arrange for ambulance transfer service between airport and hospital at the end of each trip.

C. The provider shall utilize air ambulance personnel trained and licensed at the paramedic level, and any additional personnel required by the physician in charge. Air ambulance personnel must meet all requirements of Maine Emergency Medical Services regulations, or those of a comparable jurisdiction, including having completed a course in altitude physiology and air operation safety. Copies of licensure of employees and air ambulances shall be on file with the air ambulance provider, as well as insurance certificates for each aircraft used.

D. Air ambulance equipment must comply with all regulations for air ambulance of Maine Emergency Medical Services, or comparable jurisdiction.Air ambulance equipment shall be made available for inspection from time to time, as deemed necessary by MaineCare Services and/or Maine Emergency Medical Services or comparable other jurisdiction.

E. In order to provide the medical equipment required for use in meeting the conditions of air ambulance transport, the provider shall not compromise any portion of the minimum equipment complement of any Maine licensed land ambulance required for emergency response.

5.05-2 Services for Continuous Treatment in a Hospital Outpatient Department

Providers must receive prior authorization from MaineCare Services, Prior Authorization Unit in order to transport members to and from a hospital outpatient department for treatment on a continuing basis from his or her home, nursing home, or ICF-IID. Round trips must be medically necessary and the vehicle and personnel requirements must be met. This benefit is limited to those cases in which transportation of the member is less costly than bringing the service to the member.

5.05-3 Round Trips for Specialized Services

Round trip ambulance services are covered for inpatients of hospitals and medical care facilities (including nursing facilities and ICF-IIDs) to the nearest hospital or non-hospital treatment facility, i.e. a clinic, therapy center or a physician's office, to obtain medically necessary diagnostic or therapeutic services that are not available at the institution where the member is an inpatient.

Round trip ambulance services must meet the criteria for medical necessity as set forth in Section 5.01-6.

B. Round trip services to and from a nursing facility (NF) or Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF-IID) that do not meet the definition of medical necessity and reasonableness as defined in Sections 5.01-5 and 5.01-6, are the responsibility of the NF or ICF-IID as defined in theMaineCare Benefits Manual, Chapter II, Section 67, "Nursing Facility Services", and Chapter II, Section 50, "Intermediate Care Facility for People with Mental Retardation".

5.05-4 Physician's Office

Ambulance Service to a physician's office may be covered under the following situations:

A. The trip is a round trip from a medical care facility or residence where it is less expensive to bring the member to the service than the service to the member. No payment is allowed if the trip is made only because the physician does not make calls to the member's place of residence. Round trip ambulance service to a physician's office from a nursing facility (NF) or Intermediate Care Facility forIndividuals with Intellectual Disabilities(ICF-IID) that does not meet the definition of medical necessity and reasonableness defined in Section 5.01-5 and 5.01-6 of this policy, is the responsibility of the NF or ICF-IID as defined in the MaineCare Benefits Manual, Chapter II, Section 67, "Nursing Facility Services", or Chapter II, Section 50, "Intermediate Care Facility for People with Mental Retardation", respectively.

B. When transporting a member to a hospital, if the ambulance must stop at a physician's office because of the member's need for immediate attention, the ambulance will then complete the trip to the hospital when the member is ready to leave the physician's office.

5.05-5 Medical Supplies and Services Provided by Ground Ambulances

Separate billing is not allowed for ancillary services which include:oxygen, oxygen administration supplies such as disposable oxygen masks, intravenous therapy, EKG, endotracheal intubation, pulse oximetry, telemetry and defibrillation.RN services are not billed separately.

5.05-6 Emergency Involuntary Admission to a Psychiatric Facility Ambulance Services

Ambulance services transporting members for emergency involuntary admission to a psychiatric facility ("Blue Paper") will be reimbursed at a rate consistent with Chapter III of this Section. In order to qualify for the Involuntary Admission to a Psychiatric Facility "Blue Paper" rate, the ambulance service must have a copy in the member's record of the judge-endorsed "Application for Emergency Involuntary Admission to a Psychiatric Facility."

5.05-7 Specialized Neonate Transport Services

Payment is allowed for an isolette and specialized support equipment needed to transport critically ill neonates. Services must be billed and documented as medically necessary by the attending physician.

Payment is allowed for services delivered to a neonate, between the age of birth and one (1) month. Services delivered to children older than one (1) month, but younger than two(2) years will be approved for payment if the attending physician documents the medical necessity in the member's file and forwards a copy with the bill for services.

5.05-8 Waiting Time

An ambulance service's reimbursement for Waiting Time may not exceed the cost of that ambulance's return trip to that hospital to transport that patient to a more appropriate hospital for care or back to the point of origin.

5.05-9 Air Ambulance Layover Charges

The Air Ambulance Layover Charge shall cover reasonable expenses incurred by employees of ambulance service providers who are covered under this Section of the MaineCare Benefits Manual, either when the return flight is delayed due to poor weather conditions or while waiting for the member when it has been determined that the charges while waiting would be less than making two separate trips. An air ambulance service may not be reimbursed for both layover charges and a second Basic Rate for the same member's round trip to and from a medical facility.

5.05-10 Services for Non-Ambulatory Individuals

Non-ambulatory individuals who do not require the life support emergency medical services available aboard an ambulance, but cannot, due to their disability, be transported by means of conventional transportation services shall be referred to the transportation brokerthat serves that particular regionfor a determination of the availability and suitability of wheelchair van services. For additional information please refer to Chapter II, Section 113, "Non-Emergency Transportation (NET) Services," of this Manual.

Disclaimer: These regulations may not be the most recent version. Maine may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.

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