Current through Register 1531, September 27, 2024
(A)
Criteria for Use
.
(1)
Emergency
Situations. Ambulance services are always covered in emergency
situations. An emergency situation is defined as one in which the member has a
critical or unknown illness or injury that apparently demands immediate medical
attention at a hospital to prevent permanent injury or loss of life. Emergency
cases must be transported to the nearest medical facility equipped for and
capable of treating such emergency cases.
(2)
Nonemergency
Situations. In nonemergency situations, ambulance services are
covered when medically necessary as set forth in 130 CMR 407.481(B). The return
trip of an emergency transport is considered to be a nonemergency
situation.
(B)
Conditions Always Requiring Transportation by
Ambulance.
(1)
Medical Conditions. A member who has any of the
following medical conditions always requires transportation by ambulance:
(a) continuous dependence on
oxygen;
(b) continuous confinement
to bed;
(c) classification as an
American Heart Association Class IV patient with a disease of the heart:
members with cardiac disease resulting in the inability to perform any physical
activity without discomfort. Symptoms of cardiac insufficiency or of the
anginal syndrome may be present even at rest. If any physical activity is
undertaken, discomfort is increased;
(d) receiving intravenous
treatment;
(e) after cardiac
catheterization; or
(f) having
uncontrolled seizure disorders.
(2)
Orthopedic
Conditions. A member who has either of the following orthopedic
conditions always requires transportation by ambulance:
(a) total body cast; or
(b) hip spicas or other casts that prevent
flexion at the hip.
(3)
Pediatric Conditions. A member who is in an isolette
(incubator) always requires transportation by ambulance.
(4)
Psychiatric
Conditions. A member who has either of the following psychiatric
conditions always requires transportation by ambulance:
(a) in need of restraints (possibly harmful
to himself or herself or others, including persons transported under M.G.L. c.
123, § 12 for temporary hospitalization by reason of mental illness). As
defined in M.G.L. c. 123, § 1, "likelihood of serious harm" is: "(1)
substantial risk of physical harm to the person himself or herself as
manifested by evidence of threats of, or attempts at, suicide or serious bodily
harm; (2) a substantial risk of physical harm to other persons as manifested by
evidence of homicidal or other violent behavior or evidence that others are
placed in reasonable fear of violent behavior and serious physical harm to
them; or (3) a very substantial risk of physical impairment or injury to the
person himself or herself as manifested by evidence that such person's judgment
is so affected that he or she is unable to protect himself or herself in the
community and that reasonable provision for his or her protection is not
available in the community"; or
(b)
heavily sedated.
(5)
Neurological Conditions. A member who has any of the
following neurological conditions always requires transportation by ambulance:
(a) continual confinement to bed (because of
severe brain damage, for example); or
(b) comatose.
(C)
Medical Necessity Form
Requirement.
(1) Emergency
ambulance trips do not require a Medical Necessity Form. However, the nature of
the emergency must be supported by medical records at the hospital to which the
member was transported.
(2)
Nonemergency ambulance transportation requires a Medical Necessity Form
completed in accordance with 130 CMR 407.421(D).
(D)
Recordkeeping
Requirement. Providers of ambulance services must keep records of
all services billed to the MassHealth agency. Such records must be maintained
in accordance with 130 CMR 450.205: Recordkeeping and
Disclosure and must include a log or trip sheet, separate from the
claim form, containing the vehicle number, the time of the trip, the driver's
name, the name of the member transported, the date of service, the origin and
destination of the trip, and the nature of the ambulance service provided. For
emergency trips, the nature of the emergency must be recorded in detail,
including referring source. If two or more persons are transported together,
the provider must record the name of all passengers on the log or trip sheet.
For specialty care transport, such records must include the appropriate
paramedic level credentials of the ambulance staff, or if originating facility
staff is on the vehicle, then such records must include staff names, titles,
and signatures.
(E)
Rates of Payment.
(1) Payment for ambulance services is made in
accordance with 101 CMR 327.00: Rates of Payment for Ambulance and
Wheelchair Van Services.
(2) An ambulance trip may be considered to be
a round trip if the waiting time exceeds one hour. Payment for such trips is
double the base fee, plus mileage per loaded mile after 20 miles each
way.
(3) When two patients are
transported in the same vehicle, payment for the MassHealth member is one-half
the base fee. In such instances, the mileage fee applies only once.
(4) The MassHealth agency does not pay for
additional or supplemental fees for oxygen service, for a nurse or extra
attendant, or for waiting time.
(5)
The service codes that must be used when billing for ambulance services are
listed in Subchapter 6 of the Transportation Manual.
