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  • Medical Transportation Procedures > Ambulette and Non-Emergency Ambulance

    TABLE 4
    Ambulette and non-emergency ambulance
    Service Area Medicaid FHPlus ages 19 and 20 Medicaid Advantage HMO Dual Eligible (HMO SNP) MAP-MLTC & MLTC Dual Eligible HMO/PPO SNP

     

    New York City

    Covered by Medicaid FFS

    Covered Medicaid FFS

    Covered by the Plan

    Covered by the Plan

    Covered by Medicaid FFS if member has benefit

    Nassau

    Covered by Medicaid FFS

    Covered by the Plan

    Covered by Medicaid FFS

    Covered by the Plan

    Covered by Medicaid FFS if member has benefit

    Rockland

    N/A

    N/A

    N/A

    N/A

    HMO SNP - N/A

    PPO SNP - Covered by Medicaid FFS if member has benefit

    Suffolk

    Covered by Medicaid FFS

    Covered by the Plan

    Covered by Medicaid FFS

    Covered by the Plan

    Covered by Medicaid FFS if member has benefit

    Westchester

    Covered by Medicaid FFS

    Covered by Medicaid FFS

    Covered by Medicaid FFS

    Covered by the Plan

    Covered by Medicaid FFS if member has benefit

    Prior Approval:

      • When covered by the Plan, prior approval is required. To obtain prior approval, providers must call the prior approval number on the back of the member's ID card.
      • When covered by Medicaid FFS, members or providers must call the LDSS' vendor.

      Who Arranges Services:

        • When covered by the Plan, the provider calls the prior approval number on the back of the member's ID card.
        • When covered by Medicaid FFS, the provider calls the LDSS' vendor.

        Provider Reimbursement:

          • When covered by the Plan, network transportation providers submit claims for services to the address on the back of the member's ID card.
          • When covered by Medicaid FFS, contact the LDSS' vendor for instructions.

            Medically Necessary Criteria for Approving Ambulette Services

            Medically Necessary Criteria for Approving Ambulette Services

            Ambulette Service - A special-purpose vehicle equipped to provide non-emergency care, which has either wheelchair-carrying capacity or the ability to transport disabled individuals to or from facilities that provide medical care. Ambulette services also provide personal assistance.

            Personal Assistance - Provision of physical assistance by the ambulette service employee in walking, climbing or descending stairs, ramps, curbs or other obstacles; opening or closing doors; accessing an ambulette vehicle; moving wheelchairs or other items of medical equipment; removal of obstacles as necessary to ensure the safe movement of the patient; and to touch or guide the patient in such close proximity to be able to prevent any potential injury due to a sudden loss of steadiness or balance. A patient who can walk to and from a vehicle, his or her home, or a place of medical services without such assistance does not require personal assistance.

            Prior Service Approval - Required.

            Patient Needs Service Provided Medical Criteria For Ambulette Services

            Stretcher

            Transports patients in a recumbent position. Appropriate for patients not in need of any medical care or service en route to destination.

            Patient needs to be transported in a recumbent position and the ambulette service is able to transport stretchers.

            Ambulette or Invalid Coach

            Has wheelchair-carrying capacity or the ability to transport disabled patients.

            Ambulette transportation may be ordered when a patient:

            • Is wheelchair bound and is unable to use a taxi, livery service, bus, train or private vehicle (non-collapsible wheelchair or requires a specially configured vehicle).
            • Has a disabling physical condition that requires the use of a walker or crutches and is unable to use a taxi, livery service, bus or private vehicle.
            • Requires radiation therapy, chemotherapy or dialysis treatments that result in a disabling physical condition after treatment, making the patient unable to access transportation without personal assistance provided by an ambulette service.
            • Has a severe debilitating weakness or a disabling physical condition, other than the one described above, requiring the personal assistance provided by an ambulette service; and the ordering practitioner certifies that the patient cannot be transported by a taxi, livery service, bus or private vehicle.
            • Is mentally disoriented as a result of medical treatment, or has a mental impairment or a disabling mental condition, and requires the personal assistance of the ambulette driver; and the ordering practitioner certifies that the patient cannot be transported by a taxi, livery service, bus or private vehicle (disoriented to time/place/self; acute severity hallucination; delusions/inappropriate in public situations; threat/suicidal/homicidal with a plan; acute psychotic symptomatic manic episode; chemical dependency - acute withdrawal or acute intoxication).
            • Has a functional orthopedic impairment precluding unassisted ambulation (bilateral or unilateral amputee, lower extremities; cast on lower extremity or half body; fracture of pelvic, hip, femur or leg; severe arthritis of locomotor joint).
            • Has a neuromuscular impairment precluding unassisted ambulation (spinal injury).
            • Has cerebrovascular accident with resultant hemiplegia or hemiparesis (stroke).
            • Has peripheral vascular disease precluding unassisted ambulation (severe claudication, foot ulceration).
            • Has severe respiratory disease necessitating physical assistance on stairs (emphysema, chronic obstructive pulmonary disease, chronic bronchitis).
            • Has severe cardiac disease necessitating physical assistance on stairs.
            • Other (must be provided by the ordering practitioner).

             

            Medically Necessary Criteria for Approving Ambulance Services

            Medically Necessary Criteria for Approving Ambulance Services

            An ambulance is a motor vehicle, aircraft, boat or other form of transportation designed and equipped to provide emergency medical services during transit. All Medicaid members are entitled to emergency and non-emergency ambulance service based on medical necessity.

            Emergency ambulance service - Transportation to a hospital emergency room generated by a dial 911 emergency system call or some other request for an immediate response to a medical emergency, including, but not limited to, trauma, burns, respiratory, circulatory and obstetrical emergencies. Emergency transportation is generally provided to an emergency facility. The mode of transportation for the return trip depends on the medical condition following care.

            Non-emergency ambulance service - Transportation for the purpose of obtaining necessary medical care or services by a patient whose medical condition requires transportation in a recumbent position where the patient must be transported on a stretcher or requires the administration of life support equipment, such as oxygen, by trained medical personnel. Non-emergency transportation is of a pre-planned nature and is generally provided to and from medical treatment.

            Prior Approval - Not required in emergencies; required in non-emergencies.

            Patient Needs Services Medical Criteria For Ambulance Services

            Advanced Life Support (ALS) Services

            Provides invasive treatment that is inclusive and above the level of care provided by an NYS-certified EMT, including initiation of intravenous (IV) fluids, intubations/insertion of an airway tube, defibrillation of the patient's heart, cardiac monitoring (EKG) and administration of drugs, which includes oral and all other types of medications that are stored on an ALS ambulance.

            Medical criteria for ambulance transportation includes but is not limited to the conditions below:

            • Medical or surgical disorder contraindicating active mobility and/or moderate exertion; intracranial lesion;
            • Functional orthopedic impairment precluding movement from prone positions; patient in full body cast;
            • Patient needs to be physically restrained; organic brain syndrome with acute psychosis and confusion;
            • Patient is unconscious; medically stabilized but comatose;
            • Patient must remain immobile because of fractured femur, fractured pelvis;
            • Severe respiratory disease necessitating administration of oxygen; emphysema, chronic obstructive pulmonary disease, chronic bronchitis;
            • Severe cardiac disease necessitating administration of oxygen; congestive heart failure;
            • Hospitalized patients in need of diagnostic therapeutic service at another hospital;
            • Patient requires intravenous therapy; terminally ill, requires transport home.

            Basic Life Support (BLS) Services

            Provides noninvasive treatment, including use of anti-shock trousers, cardiac (EKG) monitoring, monitoring of a patient's blood pressure, administration of oxygen, control of bleeding, splinting fractures, cardiopulmonary resuscitation, delivery of babies and monitoring of an already established intravenous solution.

            Advanced Life Support Assistive Services

            Advanced life support response where an ALS-trained employee and ALS ambulance are dispatched to the emergency scene to assist the primary ambulance.

            Transport From An Emergency Room To A Psychiatric Center

            Transportation of patient undergoing an acute episode of mental illness from an emergency room to a psychiatric hospital.

            Emergency transportation of mentally ill patients: When dealing with a patient undergoing an acute episode of mental illness, hospital and law enforcement officials are required to use an ambulance vehicle to transport persons to acute psychiatric care. They may not use non-emergency modes of transportation such as ambulette or taxi.

            Transportation Of Neonatal (Newborn) Infants To Regional Perinatal Centers

            Transportation of critically ill newborn infants between community hospitals and regional perinatal centers.

            When neonatal infants require intensive care at regional perinatal centers (RPCs): The RPC orders a hospital bed and arranges for the neonatal ambulance transportation.

            Fixed Wing Air Ambulance And Helicopter Air Ambulance

            Air transportation in life-threatening conditions as noted under medical criteria column.

            Air ambulance transportation may be ordered when:

            • Rapid transport is necessary to minimize risk of death or deterioration of the patient's condition.
            • Ground transport is not appropriate and the patient:
              • has a catastrophic, life-threatening illness;
              • is at a hospital that is unable to properly manage the medical condition and needs to be transported to a uniquely qualified facility; and life support equipment and advanced medical care is necessary during transport.

            Non-Emergency Ambulance

            Transportation of a pre-planned nature by which the patient is transported on a stretcher or requires the administration of life support equipment, such as oxygen, by trained medical personnel.

            May be ordered when the patient is in need of services that can only be administered by an ambulance service. The ordering physician must note in the patient's chart the patient's medical condition that qualifies the use of non-emergency ambulance service.

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            Glossary terms found on this page:

            The use of one or more drugs for purposes other than those for which they are prescribed or recommended.

            Treatment of malignant disease by chemical or biological antineoplastic agents.

            An itemized statement of health care services and their costs provided by a hospital, physician's office or other health care facility. Claims are submitted to the insurer or managed care plan by either the plan member or the provider for payment of the costs incurred.

            Means a medical or behavioral condition, the onset of which is sudden, that manifests itself by symptoms of sufficient severity, including severe pain, that a prudent layperson, possessing an average knowledge of medicine and health, could reasonably expect the absence of immediate medical attention to result in (a) placing the health of the person afflicted with such condition in serious jeopardy, or in the case of a behavioral condition, placing the health of such person or others in serious jeopardy; (b) serious impairment to such person’s bodily functions; (c) serious dysfunction of any bodily organ or part of such person; or (d) serious disfigurement of such person.

            Care for a person with an emergency condition.

            A hospital, ambulatory surgical facility, birthing center, dialysis center, rehabilitation facility, skilled nursing facility or other provider certified under New York Public Health Law. A hospice is a facility. An institutional provider of mental health substance abuse treatment operating under New York Mental Hygiene Law and/or approved by the Office of Alcoholism and Substance Abuse Services is a facility.

            An organization that provides comprehensive health care coverage to its members through a network of doctors, hospitals and other health care providers. Also called a Health Maintenance Organization.

            An institution which provides inpatient services under the supervision of a physician, and meets the following requirements:

            • Provides diagnostic and therapeutic services for medical diagnosis, treatment and care of injured and sick persons and has, as a minimum, laboratory and radiology services and organized departments of medicine and surgery
            • Has an organized medical staff which may include, in addition to doctors of medicine, doctors of osteopathy and dentistry
            • Has bylaws, rules and regulations pertaining to standards of medical care and service rendered by its medical staff
            • Maintains medical records for all patients
            • Has a requirement that every patient be under the care of a member of the medical staff
            • Provides 24-hour patient services
            • Has in effect agreements with a home health agency for referral and transfer of patients to home health agency care when such service is appropriate to meet the patient's requirements

            A card which allows the subscriber to identify himself or his covered dependents to a provider for health care services.

            An organization comprised of individual physicians or physicians in group practices that contracts with the managed care organization on behalf of its member physicians to provide health care services. Also called an Independent Practice Association.

            A city or county social services district as constituted by Section 61 of the New York State Social Services Law (SSL). Also called a Local Department of Social Services.

            Acronym for Medicare Advantage. An alternative to the traditional Medicare program in which private plans run by health insurance companies provide health care benefits that eligible beneficiaries would otherwise receive directly from the Medicare program.

            A jointly funded federal and state program that provides hospital and medical coverage to the low-income population and certain aged and disabled individuals.

            Professional services rendered by a physician for the treatment or diagnosis of an illness or injury.

            A medical or behavioral condition with a sudden onset that manifests itself by symptoms of sufficient severity, including severe pain, that a prudent layperson possessing an average knowledge of medicine and health could reasonably expect the absence of immediate medical attention to result in:

            • Placing the health of the person afflicted with such condition in serious jeopardy, or in the case of a behavioral condition placing the health of such person or others in serious jeopardy
            • Serious impairment to such person's bodily functions
            • Serious dysfunction of any bodily organ or part of such person
            • Serious disfigurement of such person

            Health care that is rendered by a hospital or a licensed or certified provider and is determined by EmblemHealth to meet all of the criteria listed below:

            • It is provided for the diagnosis or direct care or treatment of the condition, illness, disease, injury or ailment.
            • It is consistent with the symptoms or proper diagnosis and treatment of the medical condition, disease, injury or ailment.
            • It is in accordance with accepted standards of good medical practice in the community.
            • It is furnished in a setting commensurate with the member's medical needs and condition.
            • It cannot be omitted under the standards referenced above.
            • It is not in excess of the care indicated by generally accepted standards of good medical practice in the community.
            • It is not furnished primarily for the convenience of the member, the member's family or the provider.
            • In the case of a hospitalization, the care cannot be rendered safely or adequately on an outpatient basis or in a less intensive treatment setting and, therefore, requires the member receive acute care as a bed patient.

            The fact that a provider has prescribed a service or supplies care does not automatically mean the service or supply will qualify for reimbursement under the EmblemHealth plan. To be eligible for reimbursement by EmblemHealth, all covered services must meet EmblemHealth's medical necessity criteria, described above.

            Medically necessary with respect to Medicaid and Family Health Plus members means health care and services that are necessary to prevent, diagnose, manage or treat conditions that cause acute suffering, endanger life, result in illness or infirmity, interfere with a person's capacity for normal activity or threaten some significant handicap.

            An individual and each of his or her eligible dependents, including Medicare beneficiaries who are enrolled or participate in a benefit program and who are entitled to receive covered services from the practitioner pursuant to such benefit program and the terms of the practitioner's agreement.

            The group of physicians, hospital, and other medical care providers that a specific plan has contracted with to deliver medical services to its members.

            The physician or other provider who specifically prescribes the health care service being reviewed.

            A type of health benefit plan that allows enrollees to go outside the health plan's provider network for care, but requires enrollees to pay higher out-of-pocket fees when they do. Also called Point of Service.

            A health plan that offers benefits in-network and out-of-network. In-network services are available to enrollees at lower out-of-pocket cost than the services of non-network providers. In addition, PPO enrollees may self-refer to any network provider at any time. Also called a Preferred Provider Organization.

            The process of obtaining advanced approval of coverage for a health care service or medication. The request for services is reviewed to assess medical necessity and appropriateness of elective hospital admissions and non-emergency outpatient services before the services are provided. Also called pre-authorization or pre-certification or pre-determination.

            A medical practitioner or covered facility recognized by EmblemHealth for reimbursement purposes. A provider may be any of the following, subject to the conditions listed in this paragraph:

            • Doctor of medicine
            • Doctor of osteopathy
            • Dentist
            • Chiropractor
            • Doctor of podiatric medicine
            • Physical therapist
            • Nurse midwife
            • Certified and registered psychologist
            • Certified and qualified social worker
            • Optometrist
            • Nurse anesthetist
            • Speech-language pathologist
            • Audiologist
            • Clinical laboratory
            • Screening center
            • General hospital
            • Any other type of practitioner or facility specifically listed in the member's Certificate of Insurance as a practitioner or facility recognized by EmblemHealth for reimbursement purposes

            A provider must be licensed or certified to render the covered service. The covered service must be within the scope of the Provider's license or certification.

            Treatment of disease by X-ray, radium, cobalt or high energy particle sources.

            The geographic area in which a health plan is prepared to deliver health care through a contracted network of participating providers.

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