Ambulance Transport: Medicare Eligible Patients

When Medicare is processing ambulance transport claims, they are confirming 4 key points to determine coverage eligibility. 

1. The date of the transport
2. If the transport met medical necessity
3. The destination of the transport
4. If the transport was reasonable

If all four requirements are met, Medicare will pay 80% of the Medicare allowable and the patient is responsible for the remaining 20% unless they have secondary insurance. In some cases, the secondary insurance will cover the remaining 20%. If the patient is Medi-Cal eligible on the date of the service, they will not be billed.

To better understand each of the 4 eligibility criteria, we've outlined each point in further detail below.
1. Date of Transport: Make sure that the patient's Medicare insurance plan is eligible on the date of the transport

2. Medical Necessity: Medical necessity is established when the patient's condition is such that the use of any other method of transportation is contraindicated. In other words, the reason for the ambulance transport must be medically necessary.

3. Destination: The destination of the transport must be covered.
Covered discharge destinations are: Skilled Nursing Facilities, Assisted Living Facilities, Boarding Care Facilities, Higher Level of Care Facilities, and the patient's residence - but only if the transport to the residence happens via BLS. Critical Care Transport (CCT) to a residence is not covered.

4. Reasonableness: This means that the patient is transported to the nearest and most appropriate facility. For example, if the patient is being discharged to a skilled nursing facility which is 2 miles away but the patient or patient's family would rather have the patient discharged to a facility that is 30 miles away, Medicare would only cover the 2 miles to the nearest and most appropriate facility available.