3.1 For coverage
policy on ambulance services, refer to the TRICARE Policy Manual
(TPM),
Chapter 8, Section 1.1.
3.1.1 In contractor service areas
where suppliers routinely bill a mileage charge for ambulance services
in addition to a base rate, an additional payment based on prevailing
mileage charges shall be allowed. Charges for mileage must be based
on loaded mileage only, i.e., from the pickup of a patient to his/her
destination. It is presumed that all unloaded mileage costs are
taken into account when a supplier establishes its basic charge
for ambulance services and its rate for loaded mileage.
3.1.2 When there
are both Basic Life Support (BLS) and Advanced Life Support (ALS)
ambulances furnishing services in a state, separate prevailing profiles shall be
developed for each type.
3.1.3 BLS versus ALS. There are
situations when an advanced life support ambulance is provided but,
based on hindsight, it appears that a BLS would have sufficed. In
such cases, the question is whether ALS should be billed (since
it was provided) or whether BLS should be billed (since that was the
minimum service that would have met the patient’s needs).
3.1.4 In localities
which offer only ALS ambulance service, the type of vehicle used,
rather than the level of service, is normally the primary factor
in determining TRICARE payments. Therefore, ALS may be billed for
all transports if only ALS is offered in the locality. However,
if the provider has established a different pattern of billing for
the level of service provided, then the contractor shall recognize
the difference and allow payment to be based upon the level of services
rendered rather than the type of vehicle and crew. In other words,
in an all ALS environment where the provider has established different
billing patterns based on the level of care (e.g., emergency vs.
non-emergency), the contractor shall allow one amount for emergency
and another for non-emergency.
3.1.5 If the company has only ALS
vehicles but BLS and ALS vehicles operate in the locality, then it
is the level of service required which determines the amount allowed
by the TRICARE Program. Thus, even though the provider transported
via ALS, it may be paid ALS or BLS rates, based on the following:
• If
local ordinances or regulations mandate ALS as the minimum standard
of patient transportation, then ALS reimbursement shall be made.
• If the ALS was the
only vehicle available, then the transfer may be reimbursed at the ALS
level at the discretion of the contractor.
• If the company receives
a call and dispatches ALS, although BLS was available, then BLS shall be
paid if the patient’s condition was such that BLS would have sufficed.
There shall be justification on the claim supporting the use of
the ALS ambulance in those areas where both ALS and BLS ambulances
are available and no state or local ordinances are in effect mandating
ALS as the minimum standard transport.
3.1.6 Information shall be
shared among the contractors regarding local and state ordinances/laws
affecting payment of advanced life support ambulance transfers within
their respective jurisdictional areas/regions, the sharing of this
information among contractors should allow for the accurate processing
and payment of beneficiaries traveling outside their contract areas.
3.1.7 For ambulance
transportation to or from a Skilled Nursing Facility (SNF), the
provisions in
Chapter 8, Section 1, paragraph 4.2.14.5.4 will
apply to determine if ambulance costs are included in the SNF Prospective
Payment System (PPS) rate.
3.2 Reimbursement
For ambulance services provided on or after
October 1, 2013. DHA adopts Medicare’s Ambulance Fee Schedule (AFS)
as the TRICARE CHAMPUS Maximum Allowable Charge (CMAC) for ambulance
services, in accordance with
32 CFR 199.14(j)(1)(i)(A). DHA will follow
Medicare Claims Processing Manual, Chapter 15, and reimbursement will be
based on Medicare’s AFS, except as provided under
paragraph 3.2.1 during DHA’s transition
to the fully phased-in Medicare AFS or as found in
paragraph 3.5.3 (reimbursement
of joint response where there is no agreement between the BLS and ALS
provider) and in
paragraph 3.6.6 (treat-and-release). The AFS
is provided on the Centers for Medicare and Medicaid Services (CMS)
web site at
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AmbulanceFeeSchedule/afspuf.html.
3.2.1
TRICARE Program Transition
to Medicare AFS for Air Ambulance Services
Air
ambulance services on or after October 1, 2014, shall be paid the
greater of the Medicare AFS or the TRICARE provisional air ambulance
CMAC. For the initial transition period of October 1, 2014 through
December 31, 2015, the TRICARE provisional air ambulance CMAC shall
be calculated as 85% of the base year rate. For each subsequent
year of transition, the TRICARE provisional air ambulance CMAC shall
be calculated by reducing the base year rate an additional 15% per
year until the TRICARE provisional CMAC equals the Medicare AFS.
(For example, the provisional CMAC beginning January 1, 2016, shall
be 72.25% (0.85 x 0.85) of the base year rate; beginning January
1, 2017, 61.4% (0.85 x 0.85 x 0.85) etc.) Once the provisional CMAC
equals the AFS, the transition period is over and air ambulance
services shall be reimbursed based on Medicare’s AFS.
3.2.2 Payment Under
the AFS
• Includes
a base rate payment plus a separate payment for mileage;
• Covers both the transport
of the beneficiary to the nearest appropriate facility and all items
and services associated with such transport; and
• Does not include a
separate payment for items and services furnished under the ambulance
benefit.
Payments for
items and services are included in the fee schedule payment. Such
items and services include but are not limited to oxygen, drugs,
extra attendants, and Electrocardiogram (EKG) testing (e.g., ancillary
services) - but only when such items and services are both medically
necessary and covered by the TRICARE Program under the ambulance
benefit.
3.2.3 Components
of the AFS
The mileage rates provided in
this section are the base rates that are adjusted by the yearly Ambulance
Inflation Factor (AIF). The payment amount under the fee schedule
is determined as follows:
3.2.3.1 For ground
ambulance services, the fee schedule amount includes:
• A money amount that
serves as a nationally uniform base rate, called a “Conversion Factor”
(CF), for all ground ambulance services;
• A Relative Value Unit
(RVU) assigned to each type of ground ambulance service;
• A Geographic Adjustment
Factor (GAF) for each AFS locality area (Geographical Practice Cost
Index (GPCI));
• A
nationally uniform loaded mileage rate; and
• An additional amount
for certain mileage for a rural point-of-pickup.
3.2.3.2 For air
ambulance services, the fee schedule amount includes:
• A nationally uniform
base rate for fixed wing and a nationally uniform base rate for rotary
wing;
• A
GAF for each AFS locality area (GPCI);
• A nationally uniform
loaded mileage rate for each type of air service; and
• A rural adjustment
to the base rate and mileage for services furnished for a rural
point-of-pickup.
3.2.5 Effect of
Beneficiary Death on TRICARE Payment for Ground Ambulance Transports
In general, if the beneficiary dies before
being transported, then no TRICARE payment shall be made. Thus,
in a situation where the beneficiary dies, whether any payment under
the TRICARE ambulance benefit shall be made depends on the time
at which the beneficiary is pronounced dead by an individual authorized
by the State to make such pronouncements.
Figure 1.14-1 shows the TRICARE payment
determination for various ground ambulance scenarios in which the
beneficiary dies. In each case, the assumption is that the ambulance
transport would have otherwise been medically necessary.
Figure 1.14-1 Ground
Ambulance Scenarios In Which The Beneficiary Dies
|
Time of
Death Pronouncement
|
TRICARE
Payment Determination
|
|
Before
dispatch.
|
None.
|
|
After
dispatch, before beneficiary is loaded onboard ambulance (before
or after arrival at the point-of-pickup).
|
The
provider’s/supplier’s BLS base rate, no mileage or rural adjustment;
use the QL modifier when submitting the claim.
|
|
After
pickup, prior to or upon arrival at the receiving facility.
|
Medically
necessary level of service furnished.
|
3.2.6 Effect of Beneficiary Death
on TRICARE Payment for Air Ambulance Transports
In general,
if the beneficiary dies before being transported, then no TRICARE
payment shall be made. Thus, in a situation where the beneficiary
dies, whether any payment under the TRICARE ambulance benefit shall be
made depends on the time at which the beneficiary is pronounced
dead by an individual authorized by the State to make such pronouncements.
Figure 1.14-2 shows
the TRICARE payment determination for various air ambulance scenarios
in which the beneficiary dies. In each case, the assumption is that
the ambulance transport would have otherwise been medically necessary.
If the flight is aborted for other reasons, such as bad weather,
the TRICARE payment determination is based on whether the beneficiary
was on board the air ambulance.
Figure 1.14-2 Air
Ambulance Scenarios in Which The Beneficiary Dies
|
Time of
Death Pronouncement
|
TRICARE
Payment Determination
|
|
Prior
to takeoff to point-of-pickup with notice to dispatcher and time
to abort the flight.
|
None.
Note: This scenario includes
situations in which the air ambulance has taxied to the runway,
and/or has been cleared for takeoff, but has not actually taken
off.
|
|
After
takeoff to point-of-pickup, but before beneficiary is loaded.
|
Appropriate
air base rate with no mileage or rural adjustment; use the QL modifier
when submitting the claim.
|
|
After
the beneficiary is loaded onboard, but prior to or upon arrival
at the receiving facility.
|
As
if the beneficiary had not died.
|
3.2.7 Air Ambulance Transport Cancelled
Due to Weather or Other Circumstances Beyond the Pilot’s Control
Figure 1.14-3 shows the TRICARE payment determination
for various air ambulance scenarios in which the flight is aborted
due to bad weather, or other circumstances beyond the pilot’s control.
Figure 1.14-3 Air
Ambulance Scenarios in Which The Flight is Aborted
|
Aborted
Flight Scenario
|
TRICARE
Payment Determination
|
|
Any
time before the beneficiary is loaded onboard (i.e., prior to or
after take-off to point-of-pickup).
|
None.
|
|
Transport
after the beneficiary is loaded onboard.
|
Appropriate
air base rate, mileage, and rural adjustment.
|
3.2.8 Multiple Patient Ambulance
Transport
3.2.8.1 If two patients are transported to the same
destination simultaneously, for each TRICARE beneficiary, DHA will
allow 75% of the payment allowance for the base rate applicable
to the level of care furnished to that beneficiary plus 50% of the
total mileage payment allowance for the entire trip. The GM modifier shall be
used for reporting multiple patients on one ambulance trip.
3.2.8.2 If three
or more patients are transported to the same destination simultaneously,
then the payment allowance for the TRICARE beneficiary (or each
of them) is equal to 60% of the base rate applicable to the level
of care furnished to the beneficiary. However, a single payment
allowance for mileage shall be prorated by the number of patients
onboard. This policy applies to both ground and air transports.
3.2.9 Special Payment
Limitations
If the determination is made
that transport by air ambulance was necessary, but ground ambulance
service would have sufficed, payment for the air ambulance service
is based on the amount payable for ground transport, if less costly.
If the air transport was medically appropriate (that is, ground
transportation was contraindicated, and the beneficiary required
air transport to a hospital), but the beneficiary could have been
treated at a nearer hospital than the one to which they were transported,
the air transport payment is limited to the rate for the distance
from the point of pickup to that nearer hospital.
3.4
PI
3.4.1 PI services
are ALS services provided by an entity that does not provide the
ambulance transport. This type of service is most often provided
for an emergency ambulance transport in which a local volunteer
ambulance that can provide only BLS level of service is dispatched
to transport a patient. If the patient needs ALS services such as
EKG monitoring, chest decompression, or Intravenous (IV) therapy,
another entity dispatches a paramedic to meet the BLS ambulance
at the scene or once the ambulance is on the way to the hospital.
The ALS paramedics then provide services to the patient. This tiered
approach to life saving is cost effective in many areas because
most volunteer ambulances do not charge for their services and one
paramedic service can cover many communities. These PI services shall be
payable separate from the ambulance transport, subject to the requirements
specified below:
• Furnished in a rural
area;
• Furnished
under a contract with one or more volunteer ambulance services;
and
• Medically
necessary based on the condition of the beneficiary receiving the
ambulance service.
3.4.1.1 In addition,
the volunteer ambulance service involved shall:
• Meet the Program’s
certification requirements for furnishing ambulance services;
• Furnish services
only at the BLS level at the time of the intercept; and
• Be prohibited by
State law from billing anyone for any service.
3.4.1.2 The entity
furnishing the ALS PI service shall:
• Meet the Program’s
certification requirements for furnishing ALS services; and
• Bill all recipients
who receive ALS PI services from the entity, regardless of whether
or not those recipients are TRICARE beneficiaries.
3.4.2 For the
purposes of the PI benefit, a rural area is an area that is designated
as rural by a State law or regulation or any area outside of a Metropolitan
Statistical Area (MSA) or in New England, outside a New England
County Metropolitan Area as defined by the Office of Management
and Budget (OMB). The current list of these areas is periodically
published in the Federal Register.
3.5 Joint
Response (BLS/ALS)
3.5.1 In situations where a BLS entity provides the
transport of the beneficiary and an ALS entity provides a service
that meets the fee schedule definition of an ALS intervention (e.g.,
ALS assessment, PI services, etc.), the BLS supplier may bill the
TRICARE Program the ALS rate provided that a written agreement between
the BLS and ALS entities exists prior to submitting the TRICARE
claim. Providers/suppliers shall provide a copy of the agreement
or other such evidence (e.g., signed attestation) as determined
by the TRICARE contractor. DHA does not regulate the compensation
between the BLS entity and the ALS entity when there is an agreement
between the two entities.
3.5.2 Prior to September 13, 2018,
if there is no agreement between the BLS ambulance supplier and
the ALS entity furnishing the service, then only the BLS level of
payment shall be made. In this situation, the ALS entity’s services
are not covered, and the beneficiary is liable for the expense of
the ALS services to the extent that these services are beyond the
scope of the BLS level of payment.
3.5.3 Effective for services provided on or after
September 13, 2018, if there is no agreement between the BLS ambulance
supplier and the ALS entity furnishing the service, then only the
BLS level of payment shall be made to the BLS ambulance supplier.
In this situation, the ALS entity’s services shall be payable separate
from the ambulance transport, subject to the requirements specified
below.
3.5.3.1 The ALS provider meets the Program’s certification
requirements for furnishing ALS services and is otherwise a TRICARE-authorized
ambulance company.
3.5.3.2 The ALS
provider bills all recipients who receive ALS services from the
entity, regardless of whether or not those recipients are TRICARE
beneficiaries, with exception of ambulance membership programs.
ALS entities which offer ambulance membership programs may bill
the TRICARE Program for ALS services provided the beneficiary has
not purchased a subscription (see paragraph 4.1 for more information
on ambulance membership programs) and provided the ALS entity bills
all non-subscribing recipients who receive ALS services from the
entity, regardless of whether or not those recipients are TRICARE
beneficiaries.
3.5.3.3 The services
of an ALS provider were medically necessary based on the condition
of the beneficiary receiving the ambulance service.
3.5.3.4 The ALS provider bills using either Healthcare
Common Procedure Coding System (HCPCS) code S0207 or S0208, as appropriate.
3.5.3.5 The BLS ambulance supplier bills at the BLS
rate.
3.5.4 The contractor shall reimburse
HCPCS codes S0207 and S0208 at a rate equivalent to Medicare’s rate
for HCPCS code A0432, and shall update that rate every time Medicare
updates the rate for HCPCS code A0432. Prior to reimbursement, the
contractor shall verify that all requirements of
paragraph 3.5 have
been met, to include that no other entity has been paid for ALS
level-of-service for the episode-of-care and that the ALS entity
is not entitled to payment under
paragraph 3.4.
3.6 The cost-sharing
of ambulance services and supplies will be in accordance with the
status of the patient at the time the covered services and supplies
are rendered (
32 CFR 199.4(a)(5)).
3.6.1 Ambulance transfers from a
beneficiary’s place of residence, accident scene, or other location
to a civilian hospital, Military Treatment Facility (MTF)/Enhanced
Multi-Service Market (eMSM), Department of Veterans Affairs (
DVA)
/Veterans
Health Administration (VHA) hospital, or SNF shall
be cost-shared on an outpatient basis. Transfers from a hospital
or SNF to a patient’s residence shall also be considered an outpatient
service for reimbursement under the Program. A separate cost-share
does not apply to ambulance transfers to or from an SNF, if the
costs for ambulance transfer are included in the SNF PPS rate (see
Chapter 8, Section 1, paragraph 4.2.14.5.4).
3.6.2 Ambulance
transfers between hospitals (acute care, general, and special hospitals; psychiatric
hospitals; and long-term hospitals) and SNFs shall be cost-shared
on an inpatient basis.
3.6.3 Under the above provisions,
for ambulance transfers between hospitals, a nonparticipating provider
may bill the beneficiary the lower of the provider’s billed charge
or 115% of the TRICARE allowable charge.
3.6.4 Transfers
to an MTF/eMSM, DVA/VHA hospital,
or SNF after treatment at, or admission to, an emergency room or
civilian hospital shall be cost-shared on an inpatient basis, if
ordered by either civilian or military personnel.
3.6.5 Medically
necessary ambulance transfers from an Emergency Room (ER) to a hospital
more capable of providing the required level of care shall also
be cost-shared on an inpatient basis. This is consistent with current
policy of cost-sharing ER services as inpatient when an immediate
inpatient admission for acute care follows the outpatient ER treatment.
3.6.6 Effective
for services provided on or after September 13, 2018, DHA added
coverage for “treat-and-release” services. Treat-and-release occurs
when an ambulance responds to a call and provides medically necessary
services, but transport is not provided due to patient stabilization
or patient refusal of transport. Treat-and-release coverage is provided
when all of the following conditions are met.
3.6.6.1 The ambulance entity meets the Program’s certification
requirements for furnishing ambulance services and is otherwise
a TRICARE-authorized ambulance company. No payment shall be made
to paramedics or other first responders independent of the responding
ambulance.
3.6.6.2 The ambulance
supplier bills all recipients of treat-and-release services, regardless
of whether or not those recipients are TRICARE beneficiaries.
3.6.6.3 Treat-and-release services were medically necessary
based on the condition of the beneficiary receiving the ambulance
service. No payment shall be made if medically necessary services were
not provided.
3.6.6.4 Failure
to provide transport resulted from either a determination that the
patient’s condition had stabilized and transportation to the hospital
was no longer required, or the beneficiary refused transport after
receiving services.
3.6.6.5 The ambulance
entity bills using HCPCS code A0998.
3.6.7 The contractor shall reimburse HCPCS code A0998
at a rate equivalent to the BLS non-emergency HCPCS code A0428,
which does not include mileage. The contractor shall update the reimbursement
rate for HCPCS code A0998 each time Medicare updates the rate for
HCPCS code A0428. The contractor shall be responsible for determining
the medical necessity of the treat-and-release call.