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Jurisdiction 1 Part B
Attention: Ambulance Providers - ALS/BLS Services

Advanced Life Support (ALS) Services are only considered payable by Palmetto GBA when performed by an ALS certified provider. This applies to the following HCPCS Procedure Codes:

  • A0426 – ALS – Non Emergency
  • A0427 – ALS – Emergency
  • A0433 - ALS – Level 2 (ALS 2) 

Payment is based on the level of service provided and not on the vehicle used.

To submit a specialty care transport (SCT) for payment, there must be qualified, trained personnel/supplies and proper equipment on board. The Medicare Benefit Policy Manual, Publication 100-02, Chapter 10, Section 30.1.1 defines what is required by Medicare for a SCT transport. You can access these provisions by visiting the CMS Web site.

Providers should refer to the government regulations on ambulance services contained in CMS IOM Manual, Pub. 100-02, Chapter 10. The following points are clear in Section 10:

  • The vehicle must comply with State or local laws governing the licensing and certification of an emergency medical transportation vehicle
  • Basic Life Support (BLS) ambulances must be staffed by at least two people, at least one of whom must be certified as an emergency medical technician (EMT) by the State or local authority where the services are being furnished and be legally authorized to operate all lifesaving and life-sustaining equipment on board the vehicle
  • ALS vehicles must be staffed by at least two people, one of whom must be certified by the State or local authority as an EMT-Intermediate or an EMT-Paramedic
We understand the outgoing contractor did not consistently require this information. However, Palmetto GBA will conform to CMS regulations as stated, “When a supplier does not submit such a statement or whenever there is a question about a supplier’s compliance with any of the above requirements for vehicle and crew (including suppliers who have completed the statement), carriers will take appropriate action.”
 
Important Notes:

For All J1 Ambulance Providers:
If you are receiving the B7 denial (This provider was not certified/eligible to be paid for this procedure/service on this date of service.), you are not certified as an ALS provider of services in our system. Immediately send statement and documentary evidence that the ambulance has the equipment required by State and local authorities. Documentary evidence could include a letter from such authorities, a copy of a license, permit, certificate, etc., issued by appropriate authorities (LEMSA).

Send this information to the below address so your Provider file can be updated accordingly.

J1 MAC - Palmetto GBA
Provider Enrollment
P.O. Box 1508
Augusta, GA 30903

After provider enrollment updates your file, resubmit applicable claims for payments. If you choose to submit ALS services for payment before your file has been updated, your base rate will be denied; however, the mileage would be paid as mileage is calculated on the same payment whether it is on an ALS or BLS transport run.

It has became apparent that one of the outgoing contractors down-coded ALS services to the applicable BLS service, such as A0426 to A0428 and A0427 to A0429, when the provider was not ALS certified. Palmetto GBA does not down-code services. A provider is responsible for submitting the correct code for the service performed. 

For Hawaii, Nevada, American Samoa and Northern Mariana Islands Providers Only: 
Providers should have received a letter in September 2008 requesting that you submit your ALS certification papers to Palmetto GBA so we could update your certification in the system. There are still providers that have not submitted this information. If you have not submitted the information necessary to update your certification, please do so immediately as overpayments will be collected in the near future.

If you submit services before the system has been updated, your claims will be denied with B7 - This provider was not certified/eligible to be paid for this procedure/service.

Remember these CMS regulations that are clearly indicated in the CMS IOM Manual. 
  • Medical necessity is established when the patient's condition is such that use of any other method of transportation is contraindicated. In any case in which some means of transportation other than an ambulance could be used without endangering the individual's health, whether or not such other transportation is actually available, no payment may be made for ambulance services.
  • In all cases, the appropriate documentation must be kept on file and, upon request, presented to the carrier/intermediary. It is important to note that the presence (or absence) of a physician’s order for a transport by ambulance does not necessarily prove (or disprove) whether the transport was medically necessary.
  • The ambulance service must meet all program coverage criteria in order for payment to be made
  • The reason for the ambulance transport must be medically necessary. That is, the transport must be to obtain a Medicare covered service or to return from such a service.
  • Under the Ambulance Fee Schedule (AFS), payment is made according to the medically necessary services actually furnished. That is, payment is based on the level of service furnished (provided they were medically necessary) and not on the vehicle used. Even if a local government requires an ALS response for all calls, payment under the AFS is made only for the level of service furnished and then only when the service is medically necessary.

 

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last updated on 06/19/2009
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