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 or 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 ALS 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.
3.1.4.1 The contractor shall recognize
and allow payment to be based upon the level of services rendered rather
than the type of vehicle and crew if the provider has established
a different pattern of billing for the level of service provided.
3.1.4.2 The contractor shall allow
one amount for emergency and another for non-emergency 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).
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 The contractor shall share
information with other contractors regarding local and state ordinances/laws affecting
payment of ALS 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 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)
website 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.
Note: 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
ALS 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), 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 (i.e., 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.
3.5.5 The contractor shall verify
that all requirements of
paragraph 3.5 have been met, prior to reimbursement,
to include that no other entity has been paid for ALS level-of-service
for the episode-of-care (EOC) 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, Market/Military Medical
Treatment Facility (MTF), 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).
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 a Market/MTF, 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.
3.6.7.1 The contractor shall update
the reimbursement rate for HCPCS code A0998 each time Medicare updates
the rate for HCPCS code A0428.
3.6.7.2 The contractor shall be responsible
for determining the medical necessity of the treat-and-release call.