Billing / Insurance
FAQs
Medicare does not cover the following services:
- Transportation in Ambi-buses, ambulettes (Mobility Assistance Vehicle (MAV)), Medi-cabs, vans, privately owned vehicles, taxicabs.
- Transportation via Mobile Intensive Care Unit (MICU) ( if billed under Medicare Part A).
- Parking fees.
- Tolls for bridges, tunnels and highways.
- Medicare does not provide payment for "Ambulance response and treatment, no transport (A0998)."
Manheim Township Ambulance Association only
participates with Medicare and Pennsylvania Medicaid and NO other carriers. We
will bill all carriers on your behalf but we DO NOT accept any partial payment
as payment in full. It will be the responsibility of the patient to pay
any and all outstanding balances. Discounts to those balances, minus a
deductible will be provided to those who are subscribers to the
association.
ALL Patients have the right to have a claim excluded from
Insurance processing so NO information is submitted to any carrier.
Under these circumstances, in so doing, the patient is then agreeing to pay
out-of-pocket the full billed amount so no claim is generated to any
insurance carrier.
Any claim submitted to ANY Highmark Blue
Shield or Capital Blue Cross plan will be the responsibility of the patient as
they will send the money to the patient since we are
non-participating. They will not provide us any information on these
claims under a privacy rule they have set up and it is the patients
responsibility to contact the carrier for claim
status.
We do accept credit cards for payment (Visa, Mastercard, Discover and American Express only), please complete this form.
All claims not paid within 60 days and the patient has not called to make payment arrangements will
be submitted to collection and an additional 25% fee is added at that time. It is also reported to all 3 credit bureau reporting agencies.
Billing Coverage Issues:
A misconception is that whenever a call is made via 911 it will be paid. ALL carriers are trying to have more patient financial responsibility when it comes to healthcare and payment for services. A claim submitted must meet criteria which is different than what a physician or hospitals are reimbursed. Ambulances have been set with a limited diagnosis and medical necessity requirement for all claims.
Having Insurance whether Private or from a State or Federal program DO NOT constitute payment. All claims processing are based on diagnosis codes. ALL carriers follow federal programs and changes to those programs went into effect in April of 2012. When Medicare dropped a huge segment of the over 30,000 diagnosis codes and allocated only 73 of those for billing, all carriers followed these same guidelines in order to save money. In times past, Medicare would pay for almost all diagnosis codes and conditions. As the Federal government seeks to save money the intermediary Novitas Solutions has made changes to policy and has left the providers in the middle. Medicare states they have notified their beneficiaries by the yearly notice that "Not all services are covered by Medicare".
ALL claims are not only based on medical necessity, but reasonableness of the service as well. Medicare states in their policy that a service is only covered if furnished to a beneficiary whose medical condition at the time of the service was such that transportation by any other means would endanger the health or welfare of the patient. The medical necessity goes on the condition of the patient at the time of transport regardless of the patient's diagnosis. To be deemed medically necessary for payment, the patient MUST require both the transportation and the level of service provided. Transport must be to the closest appropriate facility regardless of patient preference. If a patient can walk to the ambulance, then the claim is excluded as Medicare feels if you can walk to the ambulance, you can walk and get into a private vehicle to be transported.
For a routine ambulance transport, ALL 3 of the following criteria must be met:
- Unable to get up from bed without assistance.
- Unable to ambulate.
- Unable to sit in a chair (including a wheelchair).
If a patient can do any of the above, the service is excluded. This is also based on the diagnosis at the time of the transport. Medical necessity is required and it does not allow transport for comfort measures or based on a need to have the patient transported to free up a bed for another patient by a facility. These are very stringent and very few of routine services have been approved by Medicare even with a form completed by the hospital, physician, nurse and/or discharge planner.
Patients who are subscribers to Manheim Township Ambulance Association are given a reduced rate should a service be denied for medical necessity. Those with a Medicare or Medicare Advantage plan are charged what would have been paid by the carrier plus a small fee for the added paperwork and filing with redetermination requests. All non-subscribers are charged the total amount submitted to the original carrier in full. Private health carriers are processed differently.
Medicare will cover emergency ambulance services when the services are medically necessary, meet the destination limits of closest appropriate facilities and are provided by an ambulance service that is licensed by the state. Emergency response means responding immediately at the Basic Life Support (BLS) or Advanced Life Support 1 (ALS1) level of service to a 911 call or the equivalent. An immediate response is one in which the ambulance supplier begins as quickly as possible to take the steps necessary to respond to the call.
The patient’s condition is an emergency that renders the patient unable to be safely transported to the hospital in a moving vehicle (other than an ambulance) for the amount of time required to complete the transport. Emergency ambulance services are services provided after the sudden onset of a medical condition. For the purposes of this LCD, acute signs and/or symptoms of sufficient severity must manifest the emergency medical condition such that the absence of immediate medical attention could reasonably be expected to result in one or more of the following:
- Place the patient’s health in serious jeopardy.
- Cause serious impairment to bodily functions.
- Cause serious dysfunction of any body organ or part.
Medicare does not cover the following services:
- Transportation in Ambi-buses, ambulettes (Mobility Assistance Vehicle (MAV)), Medi-cabs, vans, privately owned vehicles, taxicabs.
- Transportation via Mobile Intensive Care Unit (MICU) ( if billed under Medicare Part A).
- Parking fees.
- Tolls for bridges, tunnels and highways.
- Medicare does not provide payment for “Ambulance response and treatment, no transport (A0998).”
“ The patient’s condition is an emergency that renders the patient unable to be safely transported to the hospital in a moving vehicle (other than an ambulance) for the amount of time required to complete the transport. Emergency ambulance services are services provided after the sudden onset of a medical condition. For the purposes of this LCD, acute signs and/or symptoms of sufficient severity must manifest the emergency medical condition such that the absence of immediate medical attention could reasonably be expected to result in one or more of the following:
- Place the patient’s health in serious jeopardy.
- Cause serious impairment to bodily functions.
- Cause serious dysfunction of any body organ or part. ”
Medicare Redetermination Request Form - 1st Level of Appeal
Medicare Reconsideration Request Form - 2nd Level of Appeal
Medicare Request for Administrative Law Judge (ALJ) Hearing or Review of Dismissal
People with questions on services covered under a Medicare program can get information on the web at (http://www.medicare.gov) which is the website for beneficiaries, families, and caregivers or by calling 1-800- Medicare (633-4227). If you have an Advantage Plan you must then go to the website for your particular plan as these plans differ from what traditional Medicare pays for and they have different coverage policies. Telephone numbers for these plans should also be on the reverse side of your insurance card.
As a provider of services, we only have 1 year from the original date of service with which to submit a claim to Medicare. This is why we need to make sure all information for the beneficiary is correct so a claim can be submitted in a timely fashion. If a claim is denied for medical necessity, there are time limits for the patient to file an appeal as well and this needs to be within the year time frame as well.
First level of appeals is submitted to your local Medicare Administrative Contractor which for us in Pennsylvania is Novitas-Solutions, Inc.. The patient has 120 days with which to file this appeal. The forms can be obtained by visiting Medicare.gov for submission. This will also tell you where to send the appeal.
Second level of appeals is for reconsideration should you receive a denial on your first appeal. The patient has 180 days with which to file this appeal which will be submitted to an independent contractor which for us goes to a contractor in Florida. This form will be the last page you receive on the denial from your first appeal.
The third level of appeals goes to an (ALJ) Administrative Law Judge Hearing. This time frame for appeal is 60 days from the time of denial on the reconsideration. The amount in question must be greater than $150.00 for the appeal to be valid.
The fourth level of appeals is to the Medicare Appeals Council of the Departmental Appeals Board of Medicare. The time frame for this appeal is 60 days from the denial of the ALJ.
The Fifth and FINAL appeal is through a Judicial Review in Federal District Court. The time frame on this appeal is 60 days from the time of the last denial. The amount in question must be greater than $1500.00 for the claim to be valid to go to this level.
We ALWAYS recommend that ALL information submitted on any claim level be copied and a record be kept by the patient or representative thereof. We also recommend that you send the information Certified Mail, Return Receipt Requested so you can verify that your information was received. This assists you in the event Medicare says they never received it, you can then provide proof of receipt.
Information required will be copies of the ambulance PCR which can be obtained through our office. If you do not obtain this, Medicare will submit a request for us to submit it to them. You will need a copy of the hospital admissions notes, nursing notes, and physician’s notes to submit with your request for appeal. Medicare has already received a lot of this information but it helps if you submit as well.
It is found that if you are not admitted to the hospital the chances of winning on appeal greatly diminishes. IF you are admitted it may be for a different reason that what you were transported for. The hospital and physicians’ get paid on a different basis than the ambulance services. A large number of diagnoses have been eliminated for ambulance coverage. It is believed in a number of cases we did nothing to improve your care but only provided a transport which Medicare says could have been done by other means, whether it was available or not.