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TRICARE Policy Manual 6010.60-M, April 1, 2015
Other Services
Chapter 8
Section 1.1
Ambulance Service
Issue Date:  October 25, 1984
Authority:  32 CFR 199.4(d)(3)
Revision:  C-52, September 20, 2019
1.0  HCPCS PROCEDURE CODES
Level II Codes A0225, A0382, A0384, A0392, A0394, A0396, A0398, A0422, A0424 - A0436, A0998, A0999, S0207, S0208
2.0  DESCRIPTION
Transportation by means of a specifically designed vehicle for transporting the sick and injured that contains a stretcher, linens, first aid supplies, oxygen equipment, and such other safety and life saving equipment as is required by state and local law and is staffed by personnel trained to provide first aid treatment.
3.0  POLICY
Coverage is limited to the following:
3.1  Emergency transfers to or 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), or Veterans Health Administration (VHA) hospital and transfers between MTFs/eMSMs, VHA hospitals and civilian hospitals whether ordered by civilian or military personnel.
3.2  Ambulance transfers from a hospital based emergency room to an MTF/eMSM, VHA hospital or other civilian hospital more capable of providing the required care whether ordered by civilian or military personnel.
3.3  Transfers between an MTF/eMSM, or civilian hospital or skilled nursing facility and a freestanding or another hospital based outpatient therapeutic or diagnostic department/facility whether ordered by civilian or military personnel.
3.4  Ambulance services by other than land vehicles (such as a boat or airplane) shall be considered only when the pickup point is inaccessible by a land vehicle, or when great distance or other obstacles are involved in transporting the patient to the nearest hospital with appropriate facilities and the patient’s medical condition warrants speedy admission or is such that transfer by other means is contraindicated. Transporting to the nearest hospital does not apply when transporting to an MTF/eMSM as outlined in paragraph 3.5.
3.5  A claim for ambulance service to a Uniformed Services Medical Treatment Facility (USMTF) shall not be denied on the grounds that there is a nearer civilian institution (hospital) having appropriate facilities to treat the patient.
3.6  Ambulance transfer to and from skilled nursing facilities when medically indicated. See the TRICARE Reimbursement Manual (TRM), Chapter 8, Section 1, paragraph 4.2.14.5.
3.7  Payment of services and supplies provided by ambulance personnel at an accident scene shall be allowed when the patient’s condition warrants transfer to an inpatient acute setting and medical services and/or supplies are provided solely to stabilize the patient’s condition while awaiting the arrival of a more urgent means of transfer; e.g., air ambulance services.
3.8  Effective for services provided on or after September 13, 2018, medically necessary services rendered by the ambulance on-scene although the patient did not receive transport (“treat-and-release”) is a benefit under the ambulance benefit. Payment for services and supplies provided by ambulance personnel when no transport is provided shall be authorized so long as those services and supplies are medically necessary. Payment shall be made for services and supplies if the ambulance personnel determine after treatment that the patient is stabilized and does not require hospitalization, or if the patient refuses transport after being treated. Payment shall only be made to TRICARE-authorized ambulance companies; paramedics and other first responders may not independently bill for treat-and-release services. See TRM, Chapter 1, Section 14, paragraph 3.6.8.
4.0  EXCLUSIONS
4.1  Ambulance service used instead of taxi service when the patient’s condition would have permitted use of regular private transportation.
4.2  Transport or transfer of a patient primarily for the purpose of having the patient nearer to home, family, friends, or personal physician. Except as described in paragraph 3.3, transport shall be to the closest appropriate facility by the least costly means.
Note:  The exclusion of ambulance coverage “primarily for the purpose of having the patient nearer to home, family, friends, or personal physician” does not apply when the ambulance transfer is medically necessary and appropriate. If there is documentation that the ambulance transfer is for reasons of medical necessity (e.g., the need for parental nurturing of an infant as a component of or in furtherance of medical treatment; the need to place a child in an appropriate level of care) then the ambulance service is not “primarily” driven by considerations of family/patient convenience and the exclusion does not apply.
4.3  Medicabs or ambicabs which function primarily as public passenger conveyances transporting patients to and from their medical appointments.
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