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 or to a nursing facility.
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.
Notes
Iowa Code r.
441-78.11
ARC 8958C, IAB
2/19/25, effective 4/1/25
Amended by
IAB
February 19, 2025/Volume XLVII, Number 17, effective
4/1/2025
