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.