Section 471-4-004 - SERVICE REQUIREMENTS004.01GENERAL REQUIREMENTS.004.01(A)MEDICAL NECESSITY OF THE SERVICE. Medical necessity is established when the client'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 client's health, whether or not such other transportation is actually available, Medicaid will not make payment for ambulance service. Claims for ambulance services must include adequate documentation for determination of medical necessary.004.01(B)SERVICES PROVIDED FOR CLIENTS ENROLLED IN NEBRASKA MEDICAID MANAGED CARE. See 471 NAC 1.004.01(C)HEALTH CHECK SERVICES. See 471 NAC 33.004.02COVERED SERVICES. Medicaid covers medically necessary and reasonable ambulance services required to transport a client to obtain, or after receiving, a Medicaid covered service. 004.02(A)GROUND AMBULANCE SERVICES.004.02(A)(i)BASIC LIFE SUPPORT (BLS) SERVICES. Medicaid covers basic life support (BLS) ambulance services.004.02(A)(ii)ADVANCED LIFE SUPPORT (ALS) SERVICES. Medicaid covers advanced life support (ALS) ambulance services if:(1) Ambulance personnel perform advanced life support (ALS) services during the transport;(2) Advanced life support (ALS) personnel monitor the condition of a client during the transport, even if no advanced life support (ALS) services are provided during the transport; or(3) Any ambulance service not covered under 004.02(A)(ii)(1) or 004.02(A)(ii)(2) covered as a basic life support (BLS) service.004.02(A)(iii)MILEAGE. Loaded mileage is covered for total distances in excess of five loaded miles. Unloaded mileage, and the initial five loaded miles when the total distance is not in excess of five loaded miles, is covered as a part of the base rate.004.02(A)(iv)WAITING OR STANDBY TIME. Waiting or standby time under normal circumstances is covered as a part of the base rate. Waiting or standby time, in excess of thirty minutes, but less than two hours, is covered only when necessary to stabilize a client's condition. Waiting or standby time in excess of two hours is not covered.004.02(B)AIR AMBULANCE. Medicaid covers medically necessary air ambulance services only when transportation by ground ambulance is contraindicated and: (i) Great distances or other obstacles are involved in getting the client to the destination;(ii) Immediate and rapid admission is essential; or(iii) The point of pickup is inaccessible by land vehicle.004.02(C)NON-EMERGENCY TRANSPORTS. Any ambulance transport that does not meet the definition of an emergency transport will be covered as a non-emergency transport, regardless of point of origin and destination. Sufficient documentation is required to support the medical necessity of a non-emergency transport. 004.02(C)(i)TRANSPORTS TO THE FACILITY WHICH MEETS THE NEEDS OF THE CLIENT. Medicaid covers services provided by the most appropriate ambulance and practitioner type that meets the needs of the client including: (1) Medical care in a facility;(2) Support from the client's community; or(3) Care from the client's own physician or practitioner or a qualified physician, practitioner, or specialist.004.02(C)(ii)TRANSPORTS TO A PHYSICIAN'S OFFICE. Non-emergency ambulance transports to a physician or practitioner's office, clinic or therapy center are covered when: (1) The client is bed confined before, during, and after transport; and(2) The services cannot or cannot reasonably be expected to be provided at the client's residence.004.02(D)ROUND TRIP TRANSPORTS FOR HOSPITAL INPATIENTS. Ambulance services provided to a client receiving inpatient hospital services, where the client is transported to a separate facility for services, and the client is returned to the originating hospital for continuation of inpatient care, are covered as an ambulance service as opposed to a hospital service outlined in 471 NAC 10.004.02(E)TRANSPORT OF MORE THAN ONE CLIENT. When more than one client is transported during a single trip, a base rate is covered for each client transported. The number of loaded miles and mileage charges must be prorated among the number of clients being billed.004.02(F)TRANSPORT OF MEDICAL TEAMS. Transportation of a medical team resulting in an ambulance transport of the client, is covered as a part of the base rate. Transportation of a medical team without the client being in the ambulance is not covered.004.02(G)TRANSPORT OF DECEASED CLIENTS. Ambulance services are covered if the client is pronounced dead while en route to or upon arrival at the hospital. Ambulance services are not covered if a client is pronounced dead before the client is transported.004.02(H)HOSPITAL-BASED AMBULANCE SERVICE. Hospital-based ambulance services are regulated in 471 NAC 10.471 Neb. Admin. Code, ch. 4, § 004
Amended effective 5/8/2022