Payment will be approved for ambulance service if it is
required by the recipient's condition and the recipient is transported to the
nearest hospital with appropriate facilities or to one in the same locality,
from one hospital to another, to the patient's home, to a nursing facility, or
to a mental health access center. Payment for ambulance service to the nearest
hospital for outpatient service will be approved only for emergency treatment.
Ambulance service must be medically necessary and not merely for the
convenience of the patient.
(1)
Partial payment may be made when an individual is transported beyond the
destinations specified, and is limited to the amount that would have been paid
had the individual been transported to the nearest institution with appropriate
facilities. When transportation is to the patient's home, partial payment is
limited to the amount that would have been paid from the nearest institution
with appropriate facilities. When a recipient who is a resident of a nursing
care facility is hospitalized and later discharged from the hospital, payment
will be made for the trip to the nursing care facility where the recipient
resides even though it may not in fact be the nearest nursing care
facility.
(2) The Iowa Medicaid
enterprise medical services unit shall determine that the ambulance
transportation was medically necessary and that the condition of the patient
precluded any other method of transportation. Payment can be made without the
physician's confirmation when:
a. The
individual is admitted as a hospital inpatient or in an emergency
situation.
b. Previous information
on file relating to the patient's condition clearly indicates ambulance service
was necessary.
(3) When a
patient is transferred from one nursing home to another because of the closing
of a facility or from a nursing home to a custodial home because the recipient
no longer requires nursing care, the conditions of medical necessity and the
distance requirements shall not be applicable. Approval for transfer shall be
made by the local office of the department of human services prior to the
transfer. When such a transfer is made, the following rate schedule shall
apply:
One patient - normal allowance
Two patients - 3/4 normal allowance per patient
Three patients - 2/3 normal allowance per patient
Four patients - 5/8 normal allowance per patient
(4) Transportation of hospital
inpatients. When an ambulance service provides transport of a hospital
inpatient to a provider and returns the recipient to the same hospital (the
recipient continuing to be an inpatient of the hospital), the ambulance service
shall bill the hospital for reimbursement as the hospital's DRG reimbursement
system includes all costs associated with providing inpatient services as
stated in 441-paragraph 79.1(5)"j."
(5) In the event that more than one ambulance
service is called to provide ground ambulance transport, payment shall be made
only to one ambulance company. When a paramedic from one ambulance service
joins a ground ambulance company already in transport, coverage is not
available for the services and supplies provided by the paramedic.
This rule is intended to implement Iowa Code section
249A.4.
