Ambulance services most often are denied on the basis of Section 1861(s)(7) of the Act, which specifies ambulance transportation may be covered only when other means of transportation are contraindicated.

• When an ambulance transport is denied because another means of transportation could have been used, limitation of liability does not apply
• An Advance Beneficiary Notice (ABN) is not appropriate in these situations

Limitation of liability does apply (ABN is appropriate) for ambulance services when the transporting entity has a reasonable basis to believe that the transport can be done safely and effectively by land ambulance transportation.

• Medicare payment for the difference between reasonable and necessary services and items, and those actually furnished is denied as not reasonable and necessary based on Section 1862(a)(1)(A) of the Act
• When advance notice is given to the beneficiary, the service must be submitted with HCPCS modifier 'GA' (advance notice has been given to the beneficiary)

Reference:

• CMS guidance for ambulance suppliers regarding Advance Beneficiary Notice (PDF, 140 KB) 
• CMS Ambulance Services Center: www.cms.hhs.gov/center/ambulance.asp
• Medicare Benefit Policy Manual, Chapter 10, Ambulance (PDF, 170 KB) 
• Medicare Claims Processing Manual, Chapter 15, Ambulance (PDF, 481 KB)
• Code of Federal Regulations: www.gpoaccess.gov/cfr/index.html
  • § 410.40 Coverage of Ambulance Services
  • § 410.41 Requirements for Ambulance Suppliers

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