Tenn. Comp. R. & Regs. 0800-02-18-.13 - AMBULANCE SERVICES GUIDELINES
(1) All
non-emergency ground and air ambulance service provided to workers'
compensation claimants shall be pre-certified. Emergency ground and air
ambulance services may be retrospectively reviewed within three (3) business
days.
(2) All ground and air
ambulance services shall be medically necessary and appropriate. Documentation
and trip sheets shall be submitted with the bill that states the condition and
that indicates the necessity of the ground and air ambulance service provided.
It should readily indicate the need for transport via this mode rather than
another less expensive form of transportation. The service billed shall be
supported by the documentation submitted for review.
(3) Billing shall be submitted to the
employer or carrier on a properly completed CMS-1500 form (or its successor
form) by HCPCS code. Hospital based or owned providers shall submit charges on
a CMS-1500 form (or its successor form) by HCPCS code.
(4) Reimbursement shall be based upon the
lesser of the submitted charge or the amount listed in the rate tables. To the
extent permitted by federal law, the rates determined in the preceding sentence
shall also apply to air ambulance services.
Notes
Authority: T.C.A. §§ 50-6-204, 50-6-205, and 50-6-233 (Repl. 2005).
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(1) All non-emergency ground and air ambulance service provided to workers' compensation claimants shall be pre-certified. Emergency ground and air ambulance services may be retrospectively reviewed within three (3) business days.
(2) All ground and air ambulance services shall be medically necessary and appropriate. Documentation and trip sheets shall be submitted with the bill that states the condition and that indicates the necessity of the ground and air ambulance service provided. It should readily indicate the need for transport via this mode rather than another less expensive form of transportation. The service billed shall be supported by the documentation submitted for review.
(3) Billing shall be submitted to the employer or carrier on a properly completed CMS-1500 form (or its successor form) by HCPCS code. Hospital based or owned providers shall submit charges on a CMS-1500 form (or its successor form) by HCPCS code.
(4) Reimbursement shall be based upon the lesser of the submitted charge or the amount listed in the rate tables. To the extent permitted by federal law, the rates determined in the preceding sentence shall also apply to air ambulance services.
Notes
Authority: T.C.A. §§ 50-6-204, 50-6-205, and 50-6-233 (Repl. 2005).