Original Effective Date: 02-28-2000 Revised Date: 01-29-14 Page 1 of 5
MPM 1.1 Disclaimer
Refer to the member’s specific benefit plan and Schedule of Benefits to determine coverage. This may not be a benefit on all plans, or the plan may have broader or more limited benefits than those listed in this Medical Policy.
Ambulance service should be utilized when medically necessary and it is medically unsafe to move the member by a non-medical vehicle such as a car or van. Ambulance services can be either air or ground transport and can be used in an emergency situation, a high-risk situation or for inter- facility transfers.
Ambulance services do not require Prior Authorization. However, all claims are subject to retrospective review. The following coverage guidelines apply:
Medical necessity is established when the patient’s condition is such that use of any other method of transportation is contraindicated.
Ground and air ambulance services, including non-emergent medically necessary services, do not require Prior Authorization.
Ambulance services must be provided by a licensed ambulance service in a vehicle that is equipped and staffed with life-sustaining equipment and appropriately trained personnel.
High risk ambulance services must be prescribed by the member’s attending physician. High risk conditions include high risk pregnant women with impending delivery, or when it is necessary to transport a mother or infant.
Non-emergent inter-facility transfers must be medically necessary and prescribed by the member’s attending physician. The following conditions apply:
Documentation confirms that the member’s condition is such that other methods of transport are contraindicated, and that transport by ambulance is medically necessary.
As a general rule, scheduled, repetitive trips require physician certification dated no earlier than 60 days before the date of service. 6. Air ambulance is covered when medically necessary. The following conditions apply: The member’s destination must be to an acute care hospital. The member’s condition is such that ground ambulance transport would endanger the member’s life or health. Inaccessibility to ground ambulance transport or extended length of time required to transport via ground ambulance could endanger the member.
Not every Presbyterian health plan contains the same benefits. Please refer to the member’s specific benefit plan and Schedule of Benefits to determine coverage. [MPMPPC080901]