Original Effective Date: 02-28-2000 Revised Date: 01-29-14 Page 4 of 5
Inter-facility Transfer: Ground or air ambulance transportation between any of the following: hospitals, skilled nursing facilities or diagnostic facilities.
The coding listed in this Medical Policy is for reference only. Covered and non-covered codes are included within this list.
A0425 A0426 A0427 A0428 A0429 A0433 A0434 A0435 A0436 A0888
Ground mileage, per statute mile Ambulance service, ALS, non-emergency transport, level 1 Ambulance service, ALS, emergency transport, level 1 Ambulance service, BLS, non-emergency transport Ambulance service, BLS, emergency transport Advanced life support, level 2 (ALS2)
Specialty Care Transport (SCT)
Fixed wing air mileage, per statute mile Rotary wing air mileage, per statute mile
Non-covered ambulance mileage, per mile (e.g., for miles traveled beyond appropriate facility)
Centers for Medicare and Medicaid Services, Medicare Benefits Policy Manual (Pub. 100-02), Chapter 10 – Ambulance Services. Accessed on the Internet 08-27-09: Accessed on the internet 11-4-11 http://www.cms.hhs.gov/manuals/Downloads/bp102c10.pdf
New Mexico Administrative Code (NMAC): Title 13, Chapter 10, Part
D. “Basic Health Care Services: Emergency and urgent care
services.” Accessed on the Internet 08-27-09: Accessed on the Internet 11-4-11 http://www.nmcpr.state.nm.us/nmac/cgi- bin/hse/homepagesearchengine.exe?url=http://www.nmcpr.state.nm.us/ nmac/parts/title13/13.010.0013.htm;geturl;terms=13.10
New Mexico Administrative Code (NMAC): Title 8, Chapter 306, Part
D. “Services Included in the SCI Benefit Package: Emergency and urgently needed health services.” Accessed on the Internet 06-25-09: http://www.nmcpr.state.nm.us/nmac/cgi- bin/hse/homepagesearchengine.exe?url=http://www.nmcpr.state.nm.us/ nmac/parts/title08/08.306.0007.htm;geturl;terms=8.306
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]