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.