Emergency response is a BLS or ALS1 level of service provided in immediate response to a 911 call or the equivalent. An immediate response is one in which the ambulance supplier begins as quickly as possible to take the steps necessary to respond to the call.
The phrase "911 Call or Equivalent" is intended to establish the standard of the nature of the call at the time of dispatch as the determining factor.
- Regardless of the means by which the call is made (e.g., a radio call could be appropriate) the call is considered to be of an emergent nature when, based on the information available to the dispatcher at the time of the call, it is reasonable for the dispatcher to issue an emergency dispatch in light of accepted, standard dispatch protocol
- An emergency call need not come through 911 even in areas where a 911 call system exists
- The determination to respond emergently must be in accord with the local 911 or equivalent service dispatch protocol
- If the call came in directly to the ambulance supplier, then the supplier's dispatch protocol and the dispatcher's actions must meet, at a minimum, the standards of the dispatch protocol of the local 911 or equivalent service
- In areas that do not have a local 911 or equivalent service, then both the protocol and the dispatcher's actions must meet, at a minimum, the standards of the dispatch protocol in another similar jurisdiction within the State or if there is no similar jurisdiction, then the standards of any other dispatch protocol within the State
- Where the dispatch was inconsistent with this standard of protocol, including where no protocol was used, the beneficiary's condition (symptoms) at the scene determines the appropriate level of payment
- An emergency medical condition is one manifesting itself by acute symptoms of sufficient severity (including severe pain) that the absence of immediate medical attention could reasonably be expected to result in any of the following:
- Placing the beneficiary's health in serious jeopardy
- Serious impairment to bodily functions
- Serious dysfunction of any bodily organ or part
- Palmetto GBA will presume this definition to be met when documentation is submitted that clearly substantiates the emergency nature of the ambulance services provided
- Any ambulance transportation service that does not meet these criteria is considered a non-emergency service
Palmetto GBA will not change a code submitted or add any modifier that may be required for payment when processing your claim.