Land Ambulance: Reasons for Denial


The Medicare ambulance benefit is a transportation benefit only. Without a transport, there is no payable service. Ambulance transport is not covered when other means of transportation could be utilized, without endangering the patient’s health.

Non-Covered (Denied) Situations
  • When multiple ground ambulance providers respond, payment will be made only to the ambulance supplier that actually furnishes the transport to the destination. Please refer to the "Mutual Aid" article for more information about ambulance transportation involving multiple entities.
  • No payment will be made to ambulance suppliers that arrive on the scene but do not furnish a transport. Exceptions may exist. Please refer to the "Death of Beneficiary" article for more information.
  • No payment will be made for the transport of ambulance staff or other personnel when the beneficiary is not onboard the ambulance. Example: An ambulance transport to pick up a specialty care unit from one hospital to provide services to a beneficiary at another hospital.
  • If Palmetto GBA requests additional documentation, this documentation must support the medical need for the services submitted or the services will be denied
  • When the use of ambulance services was unreasonable because the treatment of the illness or injury could be provided without requiring the beneficiary to be transported to a covered destination
  • Medicare will not pay for an ambulance service when an ambulance was used for convenience or because other means of transportation were not available
  • Non-emergency ambulance services may be covered; however, limitations exist. Please refer to the "Non-Emergency Services" article for additional information.
  • The vehicle and/or staffing requirements are not met
  • The origin/destination requirements are not met (e.g., residence to physician office and residence to diagnostic center)
  • The code submitted for payment must agree with origin/destination requirements. Examples: If you submit HCPCS code/HCPCS modifier A0429HR (BLS emergency) with modifiers indicating the trip was for a hospital to residence discharge, the service will be rejected.
  • Municipalities providing ambulance services free of charge are prohibited from submitting claims to Medicare. Medicare does not pay for items or services paid for directly or indirectly by a federal, state or local government entity.

References





Last Updated: 05/28/2020