HomeMy Public PortalAboutAddendum No. 3 to Contract No. 109-2016 - Fire-Medicount Management - Professional billing services 11a6
ADDENDUM
THIS ADDS , (Number 3 to Contract No. 109-2016) is made and entered into this/
day of , 2021, by and between Richmond, Indiana, a municipal
corporation acting throug its Board of Public Works and Safety with its office at 50 North 5th Street,
Richmond, Indiana, (hereinafter referred to as "City"), and Medicount Management, Inc., 10361
Spartan Drive, Cincinnati, Ohio, 45215 (hereinafter referred to as"Contractor").
WHEREAS, City and Contractor entered into Contract No. 109-2016 on September 15,2016; and
WHEREAS, City wishes to continue to retain Contractor to continue to provide professional
billing services in connection with City of Richmond Fire Department Emergency
Medical Services (EMS) and motor vehicle accident responses for the City of
Richmond Fire Department, as set forth within the scope of Contract No. 109-2016.
NOW, THEREFORE, in consideration of the mutual promises and covenants herein contained,
including the above stated recitals, City and Contractor hereby agree as follows:
1. The City and Contractor executed and entered into Contract No. 109-2016, on
September 15, 2016, entered into Addendum No. 1 to said Agreement on June 20,
2019, and entered into Addendum Number 2 to said Agreement on 4, 2020. Pursuant
to Contract No. 109-2016, Section IV Term of Agreement, the City has an option to
renew the Agreement for an additional one-year term for the effective dates of July 1,
2021, through June 31, 2022, which option is exercised pursuant to this Addendum.
Contractor shall continue to provide said above-described professional billing
services for the City of Richmond Fire Department as identified within Contract No.
109-2016 for the additional one-year term as set forth herein. Such services shall be
performed in a manner consistent with Contract No. 109-2016, which is hereby
incorporated by reference and made a part hereof.
2. City and Contractor also wish to include and incorporate into the Agreement the
Billing Policy attached to this Addendum as Exhibit A, which Policy has been
updated in accordance with the federal Medicare guidelines. Said Policy is attached
hereto as Exhibit A and incorporated herein by reference.
3. City and Contractor expressly agree that all other terms, conditions, and covenants
contained in Contract No. 109-2016, shall be applicable to the work performed
pursuant to this Addendum, unless such term, condition or covenant conflicts with
this Addendum Number 3, in which case this Addendum Number 3 shall be
controlling.
Addendum No. 3 to Contract No. 109-2016
Page 1 of 2
4. Both parties hereby agree that with the exception of the extension of the contract date
of termination pursuant to the exercise of the option to renew the contract for the
additional one-year term, and with the exception of the inclusion of the updated
Billing Policy in accordance with the federal Medicare guidelines, Contract No. 109-
2016 shall remain intact and unchanged and in full force and effect.
5. Both parties agree that any person executing this Contract in a representative capacity
hereby warrants that he or she has been duly authorized by his or her principal to
execute this Addendum.
IN WITNESS WHEREOF, this Addend }} is execut and approved by the undersigned
representatives of the City and Contractor this /: -..day of y , 2021, to be effective
in accordance with its terms as of July 1, 2021.
"CITY" "CONTRACTOR"
THE CITY OF RICHMOND, MEDICOUNT MANAGEMENT,INC.
INDIANA by and through its 10361 Spartan Drive
Board of Public Works and Safety Cincinnati, OH 45215
B / C 1/11/�i22%ti �
Y•
Vicki Robinson, President
By: Title: / �eS e'nJ r
mily lmer,Member
By: (vA
Printed: ,Jvs'cPir' /UcnJC®ni6
Matt Evans,Member
.` s��
APPROVED: Date: aoa/
M. ayor
Date: p S /3j -e2 f
Page 2 of 2
l 1
Medicount BillingPolicy
Objective:
To assist clients of Medicount Management Inc., (hereinafter referred to as "Billing
Company") in preventing the submission of erroneous claims or engaging in unlawful
conduct that is contrary to current State and Federal health insurance laws, policies and
rules.
Policy
Federal and state laws extensively regulate health care activities to prevent fraud and
abuse. Fraud is defined as obtaining or attempting to obtain services or payments by
dishonest means with intent, knowledge, and willingness. Abuse is defined as medical or
billing practices that are inconsistent was acceptable medical, business, or fiscal standards.
Definitions
All the following Definitions are from the Code of Federal Regulations 42 Chapter IV:
Subsection 414.605 (1-9-2020) —"Emergency Response means responding immediately at
the BLS or ALS1 level of service to a 911 call or the equivalent in areas without a 911 call
system. An immediate response is one in which the ambulance entity begins as quickly as
possible to take the steps necessary to respond to the call."
Subsection 414.605 (1-9-2020)—"Advanced Life Support, level 2 (ALS2) means either
transportation by ground ambulance vehicle, medically necessary supplies and services, and
the administration of at least three medications by intravenous push/bolus or by
continuous infusion, excluding crystalloid, hypotonic,
isotonic, and hypertonic solutions (Dextrose, Normal Saline, Ringer's Lactate); or
transportation, medically necessary supplies and services, and the provision of at least one
of the following ALS procedures:
Manual defibrillation/cardioversion Endotracheal intubation
Central venous line Cardiac pacing
Chest decompression Surgical airway
lntraosseous line"
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Subsection 414.605 (1-9-2020)—"Advanced Life Support level 1 (ALS1) means
transportation by ground ambulance vehicle, medically necessary supplies and services and
either an ALS assessment by ALS personnel or the provision of at least one ALS
intervention".
Subsection 414.605 (1-9-2020)— "Advanced Life Support (ALS) Assessment is an
assessment performed by an ALS crew as part of an emergency response that was
necessary because the patient's reported condition at the time of dispatch was such that
only an ALS crew was qualified to perform the assessment. An ALS assessment does not
necessarily result in a determination that the patient requires an ALS level of service."
Subsection 414.605 (1-9-2020)—Advanced Life Support (ALS) Intervention means a
procedure that is, in accordance with State and local laws, required to be furnished by ALS
personnel.
Subsection 414.605 (1-9-2020)—"Specialty Care Transport(SCT) means interfacility
transportation of a critically injured or ill beneficiary by a ground ambulance vehicle,
including medically necessary supplies and services, at a level of service beyond the scope
of the EMT-Paramedic. SCT is necessary when a beneficiary's condition requires ongoing
care that must be furnished by one or more health care professionals in an appropriate
specialty area, for example, nursing, emergency medicine, respiratory care, cardiovascular
care, or a paramedic with additional training."
Subsection 414.605 (1-9-2020) - "Advanced Life Support (ALS) Personnel means an
individual trained to the level of the emergency medical technician-intermediate (EMT-
intermediate) or paramedic. The EMT-Intermediate is defined as an individual who is
qualified, in accordance with State and local laws, as an EMT-Basic and who is also qualified
in accordance with State and local laws to perform essential advanced techniques and to
administer a limited number of medications. The EMT-Paramedic is defined as possessing
the qualifications of the EMT Intermediate and also, in accordance with State and local
laws, as having enhanced skills that include being able to administer additional
interventions and medications." For Kentucky this would be equivalent to the Advanced
EMT (A-EMT)."
Subsection 414.605 (1-9-2020)—"Basic Life Support (BLS) means transportation by ground
ambulance vehicle and medically necessary supplies and services, plus the provision of BLS
ambulance services. The ambulance must be staffed by at least two people who meet the
requirements of state and local laws where the services are being furnished. Also, at least
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one of the staff members must be certified, at a minimum, as an emergency medical
technician-basic (EMT-Basic) by the State or local authority where the services are furnished
and be legally authorized to operate all lifesaving and life-sustaining equipment on board
the vehicle.These laws may vary from State to State.
Subsection 414.605.(1-9-2020)—"Paramedic ALS Intercept (PI) means EMT-Paramedic
services furnished by an entity that does not furnish the ground ambulance transport,
provided the services meet the requirements specified in subsection 410.40(c) of this
chapter."
Subsection 414.605 (1-9-2020) —"Loaded Mileage—means the number of miles the
Medicare beneficiary is transported in the ambulance vehicle."
Subsection 410.40(e) (1-9-2020)— "Medical necessity requirements
(1) General Rule. Medicare covers ambulance services, including fixed wing and rotary
wing ambulance services, only if they are furnished to a beneficiary whose medical
condition is such that other means of transportation are contraindicated. The
beneficiary's condition must require both the ambulance transportation itself and
the level of service provided in order for the billed service to be considered
medically necessary. Nonemergency transportation by ambulance is appropriate if
either the beneficiary is bed-confined, and it is documented that the beneficiary's
condition is such that other methods of transportation are contraindicated; or, if his
or her medical condition, regardless of bed confinement, is such that transportation
by ambulance is medically required. Thus, bed confinement is not the sole criterion
in determining the medical necessity of ambulance transportation. It is one factor
that is considered in medical necessity determinations. For a beneficiary to be
considered bed-confined, the following criteria must be met:
(i) The beneficiary is unable to get up from bed without assistance.
(ii) The beneficiary is unable to ambulate.
(iii)The beneficiary is unable to sit in a chair or wheelchair.
(2) Special rule for nonemergency, scheduled, repetitive ambulance services. Medicare
covers medically necessary nonemergency, scheduled, repetitive ambulance services
if the ambulance provider or supplier, before furnishing the service to the
beneficiary, obtains a written order from the beneficiary's attending physician
certifying that the medical necessity requirements of paragraph (d)(1) of this Section
are met. The physician's order must be dated no earlier than 60 days before the
date the service is furnished.
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(3) Special rule for nonemergency ambulance services that are either unscheduled or
that are scheduled on a nonrepetitive basis. Medicare covers medically necessary
nonemergency ambulance services that are either unscheduled or that are
scheduled on a nonrepetitive basis under one of the following circumstances:
(i) For a resident of a facility who is under the care of a physician if the ambulance
provider or supplier obtains a written order from the beneficiary's attending
physician, within 48 hours after the transport.
(ii) For a beneficiary residing at home or in a facility who is not under the direct care
of a physician, a physician certification is not required.
(iii) If the ambulance provider or supplier is unable to obtain a signed physician
certification statement from the beneficiary's attending physician, a non-
physician certification statement must be obtained.
(iv) If the ambulance provider or supplier is unable to obtain the required
certification within 21 calendar days following the date of the service, the
ambulance supplier must document its attempts to obtain the requested
certification and may then submit the claim. Acceptable documentation includes
a signed return receipt from the U.S. Postal Service or other similar services that
evidences that the ambulance supplier attempted to obtain the required
signature from the beneficiary's attending physician or other individual named in
paragraph (e)(3)(iii) of this Section.
(v) In all cases, the provider or supplier must keep appropriate documentation on
file and, upon request, present it to the contractor. The presence of the signed
certification statement or signed return receipt does not alone demonstrate that
the ambulance transport was medically necessary. All other program criteria
must be met for payment to be made.
Subsection 410.40(f) (1-9-2020)) —"Origin and destination requirements— Medicare covers
the following ambulance transportation:
(1) From any point of origin to the nearest hospital, CAH, or SNF that is capable of
furnishing the required level and type of care for the beneficiary's illness or injury. The
hospital or CAH must have available the type of physician or physician specialist needed
to treat the beneficiary's condition.
(2) From a hospital, CAH, or SNF to the beneficiary's home.
(3) From an SNF to the nearest supplier of medically necessary services not available at the
SNF where the beneficiary is a resident, including the return trip.
(4) For a beneficiary who is receiving renal dialysis for treatment of ESRD,from the
beneficiary's home to the nearest facility that furnishes renal dialysis, including the
return trip."
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Subsection 424.36 (1-9-2020)-"Signature requirements.
(a) General rule. The beneficiary's own signature is required on the claim unless the
beneficiary has died or the provisions of paragraphs (b), (c), or (d) of this Section apply. For
purposes of this Section, "the claim" includes the actual claim form or such other form that
contains an adequate notice to the beneficiary or other authorized individual that the
purpose of the signature is to authorize a provider or supplier to submit a claim to Medicare
for specified services furnished to the beneficiary.
(b) Who may sign when the beneficiary is incapable. If the beneficiary is physically or mentally
incapable of signing the claim, the claim may be signed on his or her behalf by one of the
following:
(1) The beneficiary's legal guardian.
(2) A relative or other person who receives social security or other governmental benefits
on the beneficiary's behalf.
(3) A relative or other person who arranges for the beneficiary's treatment or exercises
other responsibility for his or her affairs.
(4) A representative of an agency or institution that did not furnish the services for which
payment is claimed but furnished other care, services, or assistance to the beneficiary.
(5) A representative of the provider or the nonparticipating hospital claiming payment for
services it has furnished if the provider or nonparticipating hospital is unable to have the
claim signed per paragraph (b)(1), (2), (3), or (4) of this Section after making reasonable
efforts to locate and obtain the signature of one of the individuals specified in
paragraph (b)(1), (2), (3), or (4) of this Section.
(6) An ambulance provider or supplier with respect to emergency or non-emergency
ambulance transport services, if the following conditions and documentation
requirements are met.
(i) None of the individuals listed in paragraph (b)(1), (2), (3), or (4) of this Section was
available or willing to sign the claim on behalf of the beneficiary at the time the
service was provided;
(ii) The ambulance provider or supplier maintains in its files the following information
and documentation for at least four years from the date of service:
(A) A contemporaneous statement,signed by an ambulance employee present
during the trip to the receiving facility, that, at the time the service was
provided, the beneficiary was physically or mentally incapable of signing the
claim and that none of the individuals listed in paragraph (b)(1), (2), (3), or (4) of
this Section were available or willing to sign the claim on behalf of the
beneficiary, and
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(B) Documentation with the date and time the beneficiary was transported, and the
name and location of the facility that received the beneficiary, and
(C) Either of the following:
(1) A signed contemporaneous statement from a representative of the facility
that received the beneficiary, which documents the name of the beneficiary
and the date and time the beneficiary was received by that facility; or
(2) The requested information from a representative of the hospital or facility
using a secondary form of verification obtained at a later date, but before
submitting the claim to Medicare for payment. Secondary forms of
verification include a copy of any of the following:
(I) The signed patient care/trip report;
(ii) The facility or hospital registration/admission sheet;
(iii) The patient medical record;
(iv) The facility or hospital log; or
(v) Other internal facility or hospital records."
All the following definitions are from the Medicare Benefit Policy Manual Chapter 10
Ambulance Services (Rev 243, 04-13-18):
10.2—Necessity and Reasonableness (Rev. 1, 10-01-03)
"To be covered, ambulance services must be medically necessary and reasonable."
10.2.1—Necessity for the Service (Rev. 1, 10-01-03)
"Medical necessity is established when the patient's condition is such that use of any other
method of transportation is contraindicated. In any case in which some means of
transportation other than an ambulance could be used without endangering the individual's
health, whether or not such other transportation is actually available, no payment may be
made for ambulance services. In all cases, the appropriate documentation must be kept on
file and, upon request, presented to the carrier/intermediary. It is important to note that
the presence (or absence) of a physician's order for a transport by ambulance dos not
necessarily prove (or disprove) whether the transport was medically necessary. The
ambulance service must meet all program coverage criteria in order for payment to be
made.
In addition, the reason for the ambulance transport must be medically necessary. That is,
the transport must be to obtain a Medicare covered service, or to return from such a
service."
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10.2.2—Reasonableness of the Ambulance Trip (Rev 103; Issued 02-20-09; Effective Date:
01-05-09; Implementation Date: 03-20-09)
"Under the FS payment is made according to the level of medically necessary services
actually furnished. That is, payment is based on the level of service furnished (provided
they were medically necessary), not simply on the vehicle used. Even if a local government
requires an ALS response for all calls, payment under the FS is made only for the level of
service furnished, and then only when the service is medically necessary."
10.2.3—Medicare Policy Concerning Bed-Confinement (Rev 1, 10-01-03)
"As stated above, medical necessity is established when the patient's condition is such that
the use of any other method of transportation is contraindicated. Contractors may
presume this requirement is met under certain circumstances, including when the
beneficiary was bed-confined before and after the ambulance trip (see §20 for the
complete list of circumstances).
A beneficiary is bed-confined if he/she is:
• Unable to get up from bed without assistance;
• Unable to ambulate; and
• Unable to sit in a chair or wheelchair.
The term "bed confined" is not synonymous with "bed rest" or "nonambulatory". Bed
confinement, by itself, is neither sufficient nor is it necessary to determine the coverage for
Medicare ambulance benefits. It is simply one element of the beneficiary's condition that
may be taken into account in the intermediary's/carrier determination of whether means of
transport other than an ambulance were contraindicated."
10.2.4—Documentation Requirements
"In all cases, the appropriate
Documentation must be kept on file and, upon request, presented to the carrier. It is
important to note that neither the presence nor absence of a signed physician's order for an
ambulance transport necessarily proves (or disproves) whether the transport was medically
necessary. The ambulance service must meet all program coverage criteria in order for
payment to be made.
10.3—The Destination (Rev. 243; Issued: 04-13-18; Effective: 074-16-18; Implementation:
07-16-18)
An ambulance transport is covered to the nearest appropriate facility to obtain necessary
diagnostic and/or therapeutic services (such as a CT scan or cobalt therapy) as well as the
return transport. In addition to all other coverage requirements,this transport situation is
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covered only to the extent of the payment that would be made for bringing the service to
the patient.
Medicare covers ambulance transports (that meet all other program requirements for
coverage) only to the following destinations:
• Hospital;
• Critical Access Hospital (CAH);
• Skilled Nursing Facility(SNF);
• From a SNF to the nearest supplier of medically necessary services not available at the
SNF where the beneficiary is a resident and not in a covered Part A stay, including the
return trip;
• Beneficiary's home;
• Dialysis facility for ESRD patient who requires dialysis; or
• A physician's office is not a covered destination. However, under special
circumstances an ambulance transport may temporarily stop at a physician's office
without affecting the coverage status of the transport.
As a general rule, only local transportation by ambulance is covered, and therefore, only
mileage to the nearest appropriate facility equipped to treat the patient is covered.
However, if two or more facilities that meet the destination requirements can treat the
patient appropriately and the locality (see §10.3.5 below) of each facility encompasses the
place where the ambulance transportation of the patient began, then the full mileage to
any one of the facilities to which the beneficiary is taken is covered. Because all duly
licensed hospitals and SNFs are presumed to be appropriate sources of health care, only in
exceptional situations where the ambulance transportation originates beyond the locality of
the institution to which the beneficiary was transported, may full payment for mileage be
considered. And then, only if the evidence clearly establishes that the destination institution
was the nearest one with appropriate facilities under the particular circumstances. (See
§10.3.6 below.)The institution to which a patient is transported need not be a participating
institution but must meet at least the requirements of§1861(e)(1) or§1861(j)(1) of the
Social Security Act (the Act.) (See Pub. 100-01 Medicare General Information, Eligibility, and
Entitlement Manual, Chapter 5, "Definitions," for an explanation of these requirements.)
10.3.3—Separately Payable Ambulance Transport Under Part B versus Patient
Transportation that is Covered Under a Packaged Institutional Service
(Rev. 243; Issued:4-13-18; Effective: 7-16-18; Implementation: 7-16-18)
Transportation of a beneficiary from his or her home, an accident scene, or any other point
of origin is covered under Part B as an ambulance service only to the nearest hospital,
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critical access hospital (CAH), or skilled nursing facility(SNF) that is capable of furnishing the
required level and type of care for the beneficiary's illness or injury and only if medical
necessity and other program coverage criteria are met. An ambulance transport from a SNF
to the nearest supplier of medically necessary services not available at the SNF where the
beneficiary is a resident and not in a covered Part A stay, including the return trip, is
covered under Part B provided that the ambulance transportation was medically reasonable
and necessary and all other coverage requirements are met.
Medicare-covered ambulance services are paid either as separately billed services, in which
case the entity furnishing the ambulance service bills Part B of the program, or as a
packaged service, in which case the entity furnishing the ambulance service must seek
payment from the provider who is responsible for the beneficiary's care. If either the origin
or the destination of the ambulance transport is the beneficiary's home, then the
ambulance transport is paid separately by Medicare Part B, and the entity that furnishes the
ambulance transport may bill its A/B MAC (A) or (B) directly. If both the origin and
destination of the ambulance transport are providers, e.g., a hospital, critical access hospital
(CAH), skilled nursing facility(SNF), then responsibility for payment for the ambulance
transport is determined in accordance with the following sequential criteria.
NOTE: These criteria must be applied in sequence as a flow chart and not independently of
one another.
1. Provider Numbers:
If the Medicare-assigned provider numbers of the two providers are different,then the
ambulance service is separately billable to the program. If the provider number of both
providers is the same, then consider criterion 2, "campus".
2. Campus:
Following criterion 1, if the campuses of the two providers (sharing the same provider
numbers) are the same,then the transport is not separately billable to the program. In this
case the provider is responsible for payment. If the campuses of the two providers are
different, then consider criterion 3, "patient status." "Campus" means the physical area
immediately adjacent to the provider's main buildings, other areas and structures that are
not strictly contiguous to the main buildings, but are located within 250 yards of the main
buildings, and any of the other areas determined on an individual case basis by the CMS
regional office to be part of the provider's campus.
3. Patient Status: Inpatient vs. Outpatient
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Following criteria 1 and 2, if the patient is an inpatient at both providers (i.e., inpatient
status both at the origin and at the destination, providers sharing the same provider
number but located on different campuses), then the transport is not separately billable. In
this case the provider is responsible for payment. All other combinations (i.e., outpatient-
to-inpatient, inpatient-to-outpatient, outpatient-to-outpatient) are separately billable to
the program. In the case where the point of origin is not a provider, Part A coverage is not
available because, at the time the beneficiary is being transported, the beneficiary is not an
inpatient of any provider paid under Part A of the program and ambulance services are
excluded from the 3-day preadmission payment window.
The transfer, i.e., the discharge of a beneficiary from one provider with a subsequent
admission to another provider, is also payable as a Part B ambulance transport, provided all
program coverage criteria are met, because, at the time that the beneficiary is in transit, the
beneficiary is not a patient of either provider and not subject to either the inpatient
preadmission payment window or outpatient payment packaging requirements. This
includes an outpatient transfer from a remote, off-campus emergency department (ER)to
becoming an inpatient or outpatient at the main campus hospital, even if the ER is owned
and operated by the hospital.
Once a beneficiary is admitted to a hospital, CAH, or SNF, it maybe necessary to transport
the beneficiary to another hospital or other site temporarily for specialized care while the
beneficiary maintains inpatient status with the original provider. This movement of the
patient is considered "patient transportation" and is covered as an inpatient hospital or CAH
service and as a SNF service when the SNF is furnishing it as a covered SNF service and
payment is made under Part A for that service. (If the beneficiary is a resident of a SNF and
must be transported by ambulance to receive dialysis or certain other high-end outpatient
hospital services, the ambulance transport may be separately payable under Part B. Also, if
the beneficiary is a SNF resident and not in a Part A covered stay and must be transported
by ambulance to the nearest supplier of medically necessary services not available at the
SNF,the ambulance transport, including the return trip, may be covered under Part B.)
Because the service is covered and payable as a beneficiary transportation service under
Part A, the service cannot be classified and paid for as an ambulance service under Part B.
This includes intra-campus transfers between different departments of the same hospital,
even where the departments are located in separate buildings. Such intra-campus transfers
are not separately payable under the Part B ambulance benefit. Such costs are accounted
for in the same manner as the costs of such a transfer within a single building.
10.3.5—Locality(Rev. 236, Issued: 6-16-17, Effective: 9-18-17, Implementation: 9-18-17)
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The term "locality" with respect to ambulance service means the service area surrounding
the institution to which individuals normally travel or are expected to travel to receive
hospital or skilled nursing services. The MACs have the discretion to define locality in their
service areas.
EXAMPLE:. Mr. A becomes ill at home and requires ambulance service to the hospital. The
small community in which he lives has a 35-bed hospital. Two large metropolitan hospitals
are located some distance from Mr. A's community and both regularly provide hospital
services to the community's residents. The community is within the "locality" of both
metropolitan hospitals and direct ambulance service to either of these (as well as to the
local community hospital) is covered."
10.3.6—Appropriate Facilities (Rev. 1, 10-01-03)
The term "appropriate facilities" means that the institution is generally equipped to provide
the needed hospital or skilled nursing care for the illness or injury involved. In the case of a
hospital, it also means that a physician or a physician specialist is available to provide the
necessary care required to treat the patient's condition. However, the fact that a particular
physician does or does not have staff privileges in a hospital is not a consideration in
determining whether the hospital has appropriate facilities. Thus, ambulance service to a
more distant hospital solely to avail a patient of the service of a specific physician or
physician specialist does not make the hospital in which the physician has staff privileges
the nearest hospital with appropriate facilities.
The fact that a more distant institution is better equipped, either qualitatively or
quantitatively,to care for the patient does not warrant a finding that a closer institution
does not have "appropriate facilities." Such a
finding is warranted, however, if the beneficiary's condition requires a higher level of
trauma care or other specialized service available only at the more distant hospital. In
addition, a legal impediment barring a patient's admission would permit a finding that the
institution did not have "appropriate facilities." For example, the nearest tuberculosis
hospital may be in another State and that state's law precludes admission of nonresidents.
An institution is also not considered an appropriate facility if there is no bed available.
The contractor, however, will presume that there are beds available at the local institutions
unless the claimant furnished evidence that none of these institutions had a bed available at
the time the ambulance service was provided.
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EXAMPLE: Mr. A becomes ill at home and requires ambulance service to the hospital. The
hospital servicing the community in which he lives are capable of providing general hospital
care. However, Mr. A requires immediate kidney dialysis, and the needed equipment is not
available in any of these hospitals. The service area of the nearest hospital having dialysis
equipment does not encompass the patient's home. Nevertheless, in this case, ambulance
service beyond the locality to the hospital with equipment is covered since it is the nearest
one with appropriate facilities.
10.3.8—Ambulance Service to Physician's Office (Rev. 1, 10-01-03
These trips are covered only under the following circumstances:
• The ambulance transport is enroute to a Medicare covered destination as
described in §10.3 ; and
• During the transport,the ambulance stops at a physician's office because of the
patient's dire need for professional attention,and immediately thereafter, the
ambulance continues to the covered destination.
In such cases, the patient will be deemed to have been transported directly to a covered
destination and payment may be made for a single transport and the entire mileage of the
transport, including any additional mileage traveled because of the stop at the physician's
office.
10.3.10—Multiple Patient Ambulance Transport—(Rev 103; Issued 02-20-09; Effective
Date: 01-05-09; Implementation Date: 03-20-09)
Effective April 1, 2002, if two patients are transported to the same destination
simultaneously,for each Medicare beneficiary, Medicare will allow 75 percent of the
payment allowance for the base rate applicable to the level of care furnished to that
beneficiary plus 50 percent of the total mileage payment allowance for the entire trip.
If three or more patients are transported to the same destination simultaneously, then the
payment allowance for the Medicare beneficiary (or each of them) is equal to 60 percent of
the base rate applicable to the level of care furnished to the beneficiary. However, a single
payment allowance for mileage will be prorated by the number of patients onboard.
20—Coverage Guidelines for Ambulance Claims (Rev 103; Issued 02-20-09; Effective Date:
01-05-09; Implementation Date: 03-20-09
Conditions Review Action
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The patient was suffering from (a) The A/B MAC (A) or(B) presumes the requirement
an illness or injury, which was met if the submitted documentation indicates
contraindicated transportation the patient:
means. (§10.2) • Was transported in an emergency situation
e.g., as a result of an accident, injury or acute
illness, or
• Needed to be restrained to prevent injury to
the beneficiary or others; or
• Was unconscious or in shock; or
• Required oxygen or other emergency
treatment during transport to the nearest
appropriate facility; or
• Exhibits signs and symptoms of acute
respiratory distress or cardiac distress such as
shortness of breath or chest pain; or
• Exhibits signs and symptoms that indicate the
possibility of acute stroke; or
• Could be moved only by stretcher; or
• Was bed-confined before and after the
ambulance trip
(b) In the absence of any of the conditions listed in (a)
above additional documentation should be
obtained to establish medical need where the
evidence indicates the existence of the
circumstances listed below:
(i) Patient's condition would not ordinarily require
movement by stretcher, or
(ii) The individual was not admitted as a hospital
inpatient(except in accident cases), or
(iii)The ambulance was solely because other
means of transportation were unavailable, or
(iv)The individual merely needed assistance in
getting from his room or home to a vehicle.
(c) Where the information indicates a situation not
listed in 2(a) or 2(b) above, refer the case to your
supervisor.
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20.1.2—Beneficiary Signature Requirements—(Rev. 190, Issued: 7/11/14; Effective: 08-12-
14, Implementation 08-12-14)
Medicare requires the signature of the beneficiary, or that of his or her representative, for
both the purpose of accepting assignment and submitting a claim to Medicare. If the
beneficiary is unable to sign because of a mental or physical condition, the following
individuals may sign the claim form on behalf of the beneficiary: (1) The beneficiary's legal
guardian. (2) A relative or other person who receives social security or other governmental
benefits on behalf of the beneficiary. (3) a relative or other person who arranges for the
beneficiary's treatment or exercises other responsibility for his or her affairs. (4) A
representative of an
agency or institution that did not furnish the services for which payment is claimed, but
furnished other care, services, or assistance to the beneficiary. (5) A representative of the
provider or of the nonparticipating hospital claiming payment for services it has furnished, if
the provider or nonparticipating hospital is unable to have the claim signed in accordance
with 42 CFR 424.36(b) (1-4). (6)A representative of the ambulance provider or supplier
who is present during an emergency and/or nonemergency transport, provided that the
ambulance provider or supplier maintains certain documentation in its records for at least 4
years from the date of service. A provider/supplier (or his/her employee) cannot request
payment for services furnished except under circumstances fully documented to show that
the beneficiary is unable to sign and that there is no other person who could sign.
Medicare does not require that the signature to authorize claim submission be obtained at
the time of transport for the purpose of accepting assignment of Medicare payment for
ambulance benefits. When a provider/supplier is unable to obtain the signature of the
beneficiary, or that of his or her representative, at the time of transport, it may obtain this
signature any time prior to submitting the claim to Medicare for payment. (Note:there is a
12 month period for filing a Medicare claim, depending upon the date of service.)
If the beneficiary/representative refuses to authorize the submission of a claim, including a
refusal to furnish an authorizing signature, then the ambulance provider/supplier may not
bill Medicare, but may bill the beneficiary (or his or her estate)for the full charge of the
ambulance items and services furnished. If, after seeing this bill, the
beneficiary/representative decides to have Medicare pay for these items and services, then
a beneficiary/representative signature is required and the ambulance provider/supplier
must afford the beneficiary/representative this option within the claims filing period.
30.1.1 - Ground Ambulance Services
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EXHIBIT /k PAGE ►y OF 18
(Rev. 236, Issued: 06-16-2017, Effective: 09-18-17, Implementation:9-18-17)
Advanced Life Support Assessment
Definition: An ALS assessment is an assessment performed by an ALS crew as part of an
emergency response (as defined below) that was necessary because the patient's
reported condition at the time of dispatch was such that only an ALS crew was qualified
to perform the assessment. An ALS assessment does not necessarily result in a
determination that the patient requires an ALS level of service. In the case of an
appropriately dispatched ALS Emergency service, as defined below, if the ALS crew
completes an ALS Assessment, the services provided by the ambulance transportation
service provider or supplier shall be covered at the ALS emergency level, regardless of
whether the patient required ALS intervention services during the transport, provided
that ambulance transportation itself was medically reasonable and necessary, as
defined in section 10.2, above and all other coverage requirements are met.
Advanced Life Support, Level 1 (ALS1)/ Basic Life Support (BLS)- Emergency
Application: The determination to respond emergently with an ALS or BLS ambulance
must be in accord with the local 911 or equivalent service dispatch protocol. If the call
came in directly to the ambulance provider/supplier, then the provider's/supplier's
dispatch protocol 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 the protocol must meet, at a minimum, the standards of a dispatch
protocol in another similar jurisdiction with the state or, if there is no similar jurisdiction
within the state, 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 (for example, symptoms) at the scene
determines the appropriate level of payment.
Advanced Life Support, Level 2 (ALS2)
Application: Crystalloid fluids include fluids such as 5 percent Dextrose in water,
Saline and Lactated Ringer's. Medications that are administered by other means,for
example: intramuscular/subcutaneous injection, oral, sublingually or nebulized, do not
qualify to determine whether ALS2 level rate is payable. However, this is not an all-
inclusive list. Likewise, a single dose of medication administered fractionally(i.e., one-
third of a single dose quantity) on three separate occasions does not qualify for the ALS2
payment rate. The criterion of multiple administrations of the same drug requires a
suitable quantity and amount of time between administrations that is in accordance
with standard medical practice guidelines. The fractional administration of a single dose
37 V02/16/2021
EXHIBIT A- PAGEIOF I
(for this purpose meaning a standard or protocol dose) on three separate occasions does
not qualify for ALS2 payment.
In other words, the administration of 1/3 of a qualifying dose 3 times does not equate to
three qualifying doses for purposes of indicating ALS2 care. OneOthirs of X given 3 times
might=X(where Xis a standard/protocol drug amount), but the same sequence does
not equal 3 times X. Thus, if 3 administrations of the same drug are required to show
that ALS2 care was given, each of those administrations must be in accord with local
protocols. The run will not qualify on the basis of drug administration if that
administration was not according to protocol.
An example of a single dose of medication administered fractionally on three separate
occasions that would not qualify for the ALS2 payment rate would be the use of
Intravenous (IV) Epinephrine in the treatment of pulseless Ventricular
Tachycardia/Ventricular Fibrillation (VF/VT) in the adult patient. Administering this
medication in increments of 0.25 mg. 0.25 mg. and 0.50 mg would not qualify for the
ALS2 level of payment. This medication, according to the American Heart Association
(AHA),Advanced Cardiac Life support(ACLS)protocol, calls for Epinephrine to be
administered in 1 mg increments every 3 to 5 minutes. Therefore, in order to receive
payment for an ALS2 level of service, based in part on the administration of Epinephrine,
three separate administrations of Epinephrine in 1 mg increments must be administered
for the treatment of pulseless VF/VT.
A second example that would not qualify for the ALS2 payment level is the use of
Adenosine in increments of 2mg. 2 mg. and 2 mg for a total 6 mg in the treatment of an
adult patient with Paroxysmal Supraventricular Tachycardia (PSVT). According to ACLS
guidelines, 6 mg of Adenosine should be given by rapid intravenous push (IVP) over 1 to
2 seconds. If the first dose does not result in the elimination of the supraventricular
tachycardia within 1 to 2 minutes, 12 mg of Adenosine should be administered IVP. If
the supraventricular tachycardia persists, a second 12 mg dose of the Adenosine can be
administered for a total of 30 mg of Adenosine. Three separate administrations of the
drug Adenosine in the dosage amounts outlined in the later case would qualify for ALS2
payment.
Endotracheal intubation is one of the services that qualifies for the ALS level of payment;
therefore, it is not necessary to consider medications administered by endotracheal
intubation for the purpose of determining whether the ALS2 rate is payable. The
monitoring and maintenance of an endotracheal tube that was previously inserted prior
to transport also qualifies as an ALS2 procedure.
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1 1
Specialty Care Transport (SCT)
Application: SCT is necessary when a beneficiary's condition requires ongoing care that
must be furnished by one or more health professionals in an appropriate specialty area.
The EMT-Paramedic level of care is set by each state. Medically necessary care that is
furnished at a level above the EMT-Paramedic level of care may qualify as SCT. To be
clear, if EMT-Paramedics- without specialty care certification or qualification -are
permitted to furnish a given service in a state, then that service does not qualify for SCT.
The phrase "EMT-Paramedic with additional training"recognizes that a state may
permit a person who is not only certified as an EMT-Paramedic, but who also has
successfully completed additional education as determined by the state in furnishing
higher level medical services required by critically ill or injured patients, to furnish a level
of service that otherwise would require a health professional in an appropriate specialty
care area (for example, a nurse) to provide. "Additional training"means the specific
additional training that a state requires a paramedic to complete in order to qualify to
furnish specialty care to a critically ill or injured patient during an SCT.
Emergency Response
Definition: Emergency response is a BLS or ALS1 level of service that has been provided
in immediate response to a 911 call or the equivalent. An immediate response is one in
which the ambulance provider/supplier begins as quickly as possible to take the steps
necessary to respond to the call.
The nature of an ambulance's response (whether emergency or not) does not
independently establish or support medical necessity for an ambulance transport.
Rather, Medicare coverage always depends on, among other things, whether the
service(s)furnished is actually medically reasonable and necessary based on the
patient's condition at the time of transport.
Application:The phrase "911 call or the equivalent" is intended to establish the
standard that the nature of the call at the time of dispatch is the determining factor.
Regardless of the medium by which the call is made (e.g., a radio call could be
appropriate) the call is 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. However, the
determination to respond emergently with a BLS orALS ambulance must be in accord
with the local 911 or equivalent service dispatch protocol. If the call came in directly to
the ambulance provider/supplier, then the provider's/supplier's dispatch protocol and
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I EXHIBIT A PAGE 17 OF l$
J
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, 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 (for example, symptoms) at the scene
determines the appropriate level of payment.
The following are definitions as it relates to the Data Collection Software used by the
Ambulance Service:
Type of Dispatch—The Type of Dispatch dictates the billing policy regarding emergency or
non-emergency.
Response Type—The Response Type dictates the billing policy "CLAIM". To facilitate
accurate ambulance claim generation,the response types have been divided into two
categories: TRADITIONAL RESPONSE which is generally governed by regulations outside the
ambulance service and SPECIAL RESPONSE which is governed by the ambulance service's
internal policies.
One example of the SPECIAL RESPONSE TYPE would be STANDBY which is an optional
ambulance service and may have many varied billing rules. Other examples would be
prisoner transportation, Coroner transport, contractual transports for hospitals and other
specific institutions in the service area, etc.
Procedures:
1) Billing Company has adopted this billing policy in order to ensure compliance with any
and all applicable State and Federal Laws and regulations.
2) The Billing Company will not accept any orders or demands from their clients that could
be in violation of State/Federal laws/Regulations. Said orders or demands could be
grounds for immediate termination of the working contract between the client and the
Billing Company. Any attempts by the client to order the Billing Company or any of its
employees to violate any State/Federal laws/Regulations may have to be reported to
the appropriate regulatory organization or agency.
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