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 III - Allowances for Services
Section 144-101-III-5 - AMBULANCE SERVICES
Subsection 144-101-III-5.06 - FEE SCHEDULE

PROC. CODE

DESCRIPTION

MAXIMUM ALLOWANCE EFFECTIVE 3/1/15-12/31/19

MAXIMUM ALLOWANCE EFFECTIVE 1/1/2020

PRIOR AUTH.

REQUIRES MODIFIER

A0021

AMBULANCE SERVICE; OUT OF STATE; PER MILE TRANSPORT [Out-of-state ambulance providers bill this code.]

$2.00

$2.00

YES

A0225

AMBULANCE SERVICE; SPECIALIZED NEONATAL TRANSPORT, BASE RATE EMERGENCY ONE WAY [GROUND][Birth to 2 years of age] (SEE NOTE E)

$300.00

100% of current published Medicare rate ***

A0420

AMBULANCE WAITING TIME (ALS OR BLS), ONE HALF (1/2) HOUR INCREMENTS[starting with the second completed half hour at one half hour per unit]

$95.00

$95.00

A0424

EXTRA AMBULANCE ATTENDANT, ALS OR BLS (REQUIRES MEDICAL REVIEW)

$32.00

$32.00

YES

A0425

GROUND MILEAGE, PER STATUTE MILE

65% of current published Medicare rate*

100% of current published Medicare rate***

A0425

GROUND MILEAGE, PER STATUTE MILE-INVOLUNTARY ADMISSION TO A PSYCHIATRIC FACILITY

$8.00

$8.00

YES

SEE NOTE D

A0426

AMBULANCE SERVICE, ADVANCED LIFE SUPPORT, NON-EMERGENCY TRANSPORT, LEVEL 1 [ALS 1]

65% of current published Medicare rate*

100% of current published Medicare rate***

A0427

AMBULANCE SERVICE, ADVANCED LIFE SUPPORT, EMERGENCY TRANSPORT, LEVEL 1 [ALS 1-EMERGENCY]

65% of current published Medicare rate*

100% of current published Medicare rate***

A0428

AMBULANCE SERVICE, BASIC LIFE SUPPORT, NON-EMERGENCY TRANSPORT, [BLS]

65% of current published Medicare rate*

100% of current published Medicare rate***

A0428

AMBULANCE SERVICE, BASIC LIFE SUPPORT, NON-EMERGENCY TRANSPORT, [BLS]-INVOLUNTARY ADMISSION TO A PSYCHIATRIC FACILITY

$285.00

$285.00

YES

SEE NOTE D

A0429

AMBULANCE SERVICE, BASIC LIFE SUPPORT, EMERGENCY TRANSPORT [BLS-EMERGENCY]

65% of current published Medicare rate*

100% of current published Medicare rate***

A0430

AMBULANCE SERVICE, CONVENTIONAL AIR SERVICES, TRANSPORT, ONE-WAY [FIXED WING] (SEE NOTE B)

65% of current published Medicare rate*

100% of current published

Medicare rate***

**

A0431

AMBULANCE SERVICE, CONVENTIONAL AIR SERVICES, TRANSPORT, ONE-WAY [ROTARY WING] (SEE NOTE C)

65% of current published Medicare rate*

100% of current published Medicare rate***

**

A0433

ADVANCED LIFE SUPPORT, LEVEL 2 [ALS 2]

65% of current published Medicare rate*

100% of current published Medicare rate***

A0434

SPECIALTY CARE TRANSPORT [SCT]

65% of current published Medicare rate*

100% of current published Medicare rate***

A0435

FIXED WING AIR MILEAGE, PER STATUTE MILE

65% of current published Medicare rate*

100% of current published Medicare rate***

**

A0436

ROTARY WING AIR MILEAGE, PER STATUTE MILE

65% of current published Medicare rate*

100% of current published Medicare rate***

**

A0998

AMBULANCE RESPONSE AND TREATMENT, NO TRANSPORT

$95.00

$95.00

A0999

UNLISTED AMBULANCE SERVICE (SEE NOTE A)

See Note A

YES