42 CFR 410.40 - Insurance coverage for emergency medical services. (2023)

§ 410.40 Coverage for emergency medical services.

(A) The definition.As used in this section, the following definitions apply:

Non-medical certification statementmeans a statement signed and dated by an individual certifying that medically necessary provisionsParagraph (e)(1)of this Section, all criteria in paragraphs (i) through (iii) of this definition are met and met. The statement does not have to be a stand-alone document, and a specific format or title is not required.

(EU)has personal knowledge of the Beneficiary's condition at the time of requesting the ambulance or providing the service;

(you)Who needs to be employed:

(A)By the beneficiary's attending physician; any

(B)By the hospital or center where the Beneficiary is treated and from which the Beneficiary is transported;

(iii)Includes the following persons, to whom all applicable Medicare regulations and all applicable state licensing laws apply:

(A)Assistant Physician (PA).

(B)Nurse (NP).

(C)Specialist Clinical Nurse (CNS).

(Video) Doctors Certifying the Need for Routine Scheduled Ambulance Transports

(D)Registered Nurse (RN).

(mi)Licensed Practical Nurse (LPN).

(F)Social worker.

(GRAMS)Fall Manager.

(H)download scheduler.

medical certificatemeans a statement signed and dated by the Beneficiary's attending physician certifying that the provisions of the Medical Necessity have been metParagraph (e)(1)of this section are met. The statement does not have to be a stand-alone document, and a specific format or title is not required.

(B) game rules.Medicare Part B covers emergency medical services if the following conditions are met:

(1)Supplier shall comply with applicable vehicle, staffing, billing and reporting requirements for§ 410.41and the service meets the medical need and origin and destination requirementsparagraphsY(F)this section.

(2)No Medicare Part A payments will be made, directly or indirectly, for the Services.

(C) Service level.Medicare covers the following levels of emergency medical services, defined in§ 414.605 of this chapter:

(1)Basic Life Support (BLS) (emergency and non-emergency).

(2)Extended Life Support, Level 1 (ALS1) (Emergency and Non-Emergency).

(Video) 10/20/2022 Ask-the-Contractor About the RSNAT Process Encore

(3)Advanced Life Support, Level 2 (ALS2).

(4)Medic ALS Interception (PI).

(5)Special Transport (SCT).

(6)Fixed Wing Transport (FW).

(7)transport of rotary vanes (RW).

(D) Paramedic ALS Intercept Services.Paramedic ALS interception services must meet the following requirements:

(1)Established in an area designated as a rural area by state law or regulation or located in a rural census tract of a metropolitan statistical area (as provided in the latest Goldsmith Amendment). (The Goldsmith Modification is a method of identifying small towns and rural areas within large metropolitan areas isolated by distance or other characteristics of central areas.)

(2)Be employed by one or more voluntary rescue services that meet the following conditions:

(EU)They are certified to provide emergency medical services in accordance with the requirements of§ 410.41.

(you)Provide services only at the BLS level.

(iii)State law prohibits you from charging for services.

(3)Provided by a Paramedic ALS Intercept provider that meets the following conditions:

(EU)Is certified to provide ALS services in accordance with the requirements of§410.41(b)(2).

(you)Charges all beneficiaries who receive ALS wiretapping services from the company, whether or not they are Medicare beneficiaries.

(mi) Medical Necessity Requirements-

(1) General rule.Medicare covers ambulance services, including fixed-wing and rotary-wing ambulance services, only when provided to a beneficiary whose medical condition is such that other means of transportation are contraindicated. The recipient's condition must require both the ambulance itself and the level of service provided for the billed service to be considered medically necessary. Non-emergency transport is appropriate when: the recipient is bedridden and there is documentation that the recipient's condition is such that other methods of transport are contraindicated; or if your state of health, apart from being bedridden, is such that transport by ambulance is medically necessary. Therefore, being bedridden is not the only criterion for the medical need to transport a patient. This is a factor taken into account when determining medical need. For a beneficiary to be considered bedridden, the following criteria must be met:

(EU)Recipient cannot get out of bed without assistance.

(you)Beneficiary cannot walk.

(iii)Beneficiary cannot sit in a chair or wheelchair.

(2) Special rule for non-emergency, scheduled and recurring redemptions.

(EU)Medicare covers medically necessary, non-emergency, scheduled, and recurring ambulance services if the ambulance provider obtains a medical certificate prior to providing the service to the beneficiary, dated within 60 days of the date the service was provided.

(you)In any case, the provider or provider must keep the relevant documents and present them to CMS when requested. The rescue service must meet all program coverage criteria, including vehicle and personnel requirements. Although a signed medical certificate (PCS) does not by itself demonstrate that the ambulance transport was medically necessary, the PCS and additional documentation from the beneficiary's medical record may be used to support a claim that the ambulance transport was medically necessary. necessary. The PCS and supporting documentation must contain detailed statements consistent with the Beneficiary's current medical condition that explain the Beneficiary's need for ambulance transport as described below.§410.41(a), including observation or other services provided by qualified ambulance personnel as described in§ 410.41 (b).

(3) Special rule for non-emergency ambulance services that are not scheduled or are scheduled on a non-recurring basis.Medicare covers medically necessary, unscheduled, or unscheduled non-emergency ambulance transport in any of the following circumstances:

(EU)For a resident of a facility being treated by a physician, if the ambulance provider or provider receives a medical note within 48 hours of transport.

(you)For a beneficiary who lives at home or in an institution and is not under direct medical care. No medical certificate is required.

(iii)If the ambulance provider is unable to obtain a medical certificate signed by the beneficiary's attending physician, a non-medical certificate must be obtained.

(4)If the ambulance provider or provider is unable to obtain the required medical or non-medical certification within 21 calendar days from the date of service, the ambulance provider or provider must document its attempts to obtain the requested certification and may then submit the claim. . Acceptable documentation includes a certificate from the US Postal Service or other similar service showing that the Ambulance Provider attempted to obtain the necessary signature from the Beneficiary's attending physician or other designeeParagraph (e)(3)(iii)this section.

(v)In any case, the provider or supplier must keep the relevant documents and present them to the contractor when requested. The presence of the medical or non-medical certificate or the signed acknowledgment does not in itself prove that the patient's transport was medically necessary. All other program criteria must be met for payment to occur.

(F) Source and destination requirements.Medicare covers the following ambulance services:

(1)From any place of origin to the nearest hospital, CAH, Hospital Rural de Emergência (REH) or SNF that is able to provide the level and type of care necessary for the beneficiary's illness or injury. The hospital or CAH or REH must have the type of doctor or specialist needed to treat the beneficiary's condition.

(2)From the hospital, CAH, REH or SNF to the beneficiary's home.

(3)From an SNSF to the nearest provider of necessary medical services not available in the SNSF where the beneficiary resides, including round-trip travel.

(4)For a Beneficiary receiving renal dialysis for the treatment of end-stage renal failure, from the Beneficiary's place of residence to the nearest facility offering renal dialysis, including round trips.

(5)During a public health emergency as defined in§ 400,200 of this chapter, a ground ambulance from any origin to a destination equipped to treat the patient's condition in accordance with an applicable state or local emergency medical services protocol governing the destination. These destinations include, but are not limited to, alternate sites designated as part of a hospital, critical access hospital, REH (as of January 1, 2023) or skilled nursing facilities, community mental health centers, qualified health centers throughout country, federal, rural health clinics, physicians' offices, emergency care centers, ambulatory surgical centers, any location where dialysis services are provided outside of an ESRD facility when an ESRD facility is not available, and the recipient's home.

(GRAMS) Specific Limitations on Ambulance Coverage Outside the United States.When services are provided outside the United States, Medicare Part B covers medical transportation to a foreign hospital only in connection with the beneficiary's admission for medically necessary inpatient services as specified inSubpart H of Part 424 of this Chapter.

[64FR 3648, January 25, 1999, as amended65FR 13914, March 15, 2000;67FR9132, February 27, 2002;77 FR69362, November 16, 2012;84 FR63187, November 15, 2019;85FR 19286, April 6, 2020;87FR 70223, November 18, 2022;87FR 72285, November 23, 2022]

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