AdminaStar provides information on air ambulance Medicare reimbursement

Submitted by LINDY LADY
AdminaStar Federal

Medical Review (MR) of Rural Air Ambulance Services  

The Centers for Medicare & Medicaid Services (CMS) has revised Chapter 6 “Intermediary MR Guidelines for Specific Services” of the Medicare Program Integrity Manual to include Section 6.4 – Medical Review of Rural Ambulance Services.

This article provides information on Medicare’s implementation of Section 415 of the MMA, which amends the Social Security Act (SSA) (Section 1834(l)) to provide appropriate coverage of rural air ambulance services. A summary of these changes includes:

Reasonable Requests

When performing a medical review of rural air ambulance claims, your Medicare carrier/ fiscal intermediary must determine if a physician or other qualified medical personnel who reasonably determined or certified that the individual’s condition required air transport due to time or geographical factors requested the transport. Medicare considers the following personnel qualified to order air ambulance services:

 -  Physician, 
 -  Registered Nurse Practitioner (from the transferring hospital),
 -  Physician’s Assistant (from the transferring hospital),
 -  Paramedic or Emergency Medical Technician (EMT) (at the scene), and
 -  Trained First Responder (at the scene)

Emergency Medical Services ( EMS ) Protocols

Please note that the reasonable and necessary requirement for rural air transport can be “deemed” to be met when service is provided pursuant to an established state or regional protocol that has been recognized or approved by the Secretary of the Department of Health and Human Services, which administers Medicare through its Centers for Medicare & Medicaid Services.

Air ambulance providers anticipating transports will be made pursuant to such a state or regional protocol must submit the written protocol to their Carrier/FI in advance for review and approval.  

At this time, Part B Medical Review is responsible for the review and approval of the protocol(s) followed when determining if rural air transportation is appropriate for a beneficiary for a Part B Provider.  You may submit a letter requesting Part B review of your protocols and a copy of your protocols to:

AdminaStar Federal
Attn: Laura Lynn Griffin
Medical Review Part B – SC-2
PO Box 37630
Louisville , KY 40233-7630  

Your request and protocols will be accepted via fax at (502) 423-2471 or electronically at laura.griffin@anthem.com.

AdminaStar Federal must review the protocol to ensure the contents are consistent with the statutory requirements of 1862(1)(A) directing that all services paid for by Medicare must by reasonable and necessary for the diagnosis or treatment of an illness or injury. The carrier will notify you of its protocol review determinations within 30 days of receipt of the protocol. Remember that you must adhere to all requirements in the Act at 1861 (s) (7) and regulatory requirements at 42CFR 424.10 which directs that all services paid by Medicare must be reasonable and necessary including the requirement that payment can be made only to the closest facility capable of providing the care needed by the beneficiary.

Prohibited Air Ambulance Relationships

Your carrier/intermediary will not apply the “deemed” reasonable and necessary determination in the following cases:

 - If there is a financial or employment relationship between the person requesting the air ambulance service and the entity furnishing the service;
-  If an entity is under common ownership with the entity furnishing the service; or
 - If there is a financial relationship between an immediate family member of the person requesting the service and the entity furnishing the service.

The only exception to this provision occurs when the referring hospital and the entity furnishing the air ambulance service are under common ownership. Then the above limitation does not apply to remuneration by the hospital for provider based physician services furnished in a hospital reimbursed under Part A and the amount of the remuneration is unrelated directly or indirectly to the provision of rural air ambulance services.

Reasonable and Necessary Services

Medicare carriers and intermediaries may perform medical review of rural air ambulance claims with “deemed” medical necessity status when there are questions as to whether:

 -  The decision to transport was reasonably made,
 -  The transport was made pursuant to an approved protocol, or
 -  The transport was inconsistent with an approved protocol.

In addition, the carrier/intermediary may conduct a medical review in those instances where there is a financial or employment relationship between the person requesting the air ambulance transport and the person providing the transport.

Additional Information

For purposes of these revised sections of the Medicare Program Integrity Manual, the term “rural air ambulance service” means fixed wing and rotary wing air ambulance services in which the point of pick up of the individual occurs in a rural area (as defined in Section 1886(d)(2)(D)) or in a rural census tract of a metropolitan statistical area (as determined under the most recent modification of the Goldsmith Modification published in the Federal Register on February 27, 1992 (57 Fed. Reg. 6725). The official instruction issued to your carrier/intermediary regarding this change, including the revised portion of Chapter 6 of the Medicare Program Integrity Manual may be found at:
http://www.cms.hhs.gov/manuals/transmittals/comm_date_dsc.asp    
From that web page, look for CR 3571 in the CR NUM column on the right and click on the file for that CR.  If you have any questions, please contact your carrier/intermediary at their toll-free number, which may be found at: http://www.cms.hhs.gov/medlearn/tollnums.asp

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