Ambulances transport critically ill or injured passengers to hospitals every day. They also take patients with non-emergency conditions to hospitals, critical access hospitals, skilled nursing facilities, nursing homes and other medical facilities to treat serious health conditions. Some of these transports are scheduled in advance, and some are not. Both emergency and non-emergency ambulance services may be covered by Medicare if it is established that using any other kind of transportation would endanger your health.
When Medicare establishes that other means of transportation would harm your health, 'medical necessity' is proven. Medicare determines medical necessity by examining the notes the ambulance personnel make while documenting your trip. For non-emergency services, Medicare also requires a signed statement from your doctor indicating that you must be transported by an ambulance due to your condition.
Sometimes the ambulance company will ask you to sign an Advance Beneficiary Notice of Noncoverage, or ABN. They can only do this for non-emergency services, and only when they believe that Medicare won’t pay for the service. Always read an ABN carefully. An ABN explains that if you want the service, you will assume payment responsibility if Medicare doesn’t cover the transport. The ambulance company can ask you to pay at the time of the service. If you refuse to sign the ABN, the ambulance company can still transport you, but you may still be responsible for the service if Medicare doesn’t deem it medically necessary.
Limitations on Medicare’s Coverage
Nearest Facility
Medicare pays for medically necessary ambulance transports to the closest facility that can provide you with the level of care or services you needed. If you want to be taken farther way, Medicare will only pay the mileage to the nearest appropriate facility. You will be responsible for the excess mileage costs.
Other Means of Transportation
Medicare can only pay for ambulance transports when it is proven that any other means of transportation would harm your health, even if other ways of transportation are not available.
Required Documentation
Written Doctor’s Order (Non-Emergency Services)
To establish medical necessity, Medicare requires ambulance suppliers to submit documentation that shows any other means of transportation would have harmed your health at the time of the service. For most non-emergency services, a written doctor’s order is required. Medicare regulations also state that the presence of a signed physician’s order does not, in and of itself, prove medical necessity. It’s the total picture the ambulance company paints of what happened during the transport and why their services were needed that allows Medicare to pay.
Your Signature (All Services)
In order to file the claim to Medicare, the ambulance company must obtain your signature (or that of an authorized representative). Your signature allows the ambulance company to accept Medicare assignment and also shows that you are allowing them to bill Medicare for the service. You do not have to provide your signature at the time of the transport, but you must do so within the claims filing time period (within 12 months of the date of the service).
If you or your representative refuses to sign, then the ambulance company can’t bill Medicare, and you will be responsible for the full amount of the transport. If you change your mind any time during the claims filing period, you can contact the ambulance company.
If you are unable to sign and an authorized representative can’t be found, then an ambulance employee present during the trip would need to provide a signed statement which includes:
• The date and time of the transport
• Why you were unable to sign
• An indication that no legally authorized person was available to sign on your behalf
• The name and location of the facility you were transported to
An employee from the receiving facility would also need to sign a statement that includes your name and the date and time you were brought there. If the ambulance company doesn’t get this information from the facility, with your permission, they can send Medicare a signed patient care report, your hospital registration or admission sheet or other hospital records that would support why you were not able to sign on your own.
What You Can Do If Medicare Doesn’t Pay
If Medicare denies your claim and you don’t agree, you can file an appeal. The last page of the Medicare Summary Notice (MSN) that you receive from Railroad Medicare explains your appeal rights. The page also explains how to file an appeal and gives the date that we must receive your appeal by.
There are five different levels in the appeals process. If you don’t agree with the first level of appeal, you can request the second level. If you still don’t agree, you can request the third level and then the fourth, and finally the fifth. The decision letter you receive at each level of appeal will explain additional appeal rights you may have. You should read these decision letters carefully.
• 1st level – Redetermination – You need to file a redetermination within 120 days from the date of your MSN. We assume you received your MSN within five days from the date of the notice. To file an appeal, follow the instructions on your MSN and return the completed, signed form to our office at the following address:
Railroad Medicare – Palmetto GBA
Attn: Redeterminations
P. O. Box 10066
Augusta, GA 30999
• 2nd level – Reconsideration – This is the second level of appeals and is requested if you don’t agree with the redetermination decision. You have to ask for a Reconsideration within 180 days from the date of your redetermination letter. The second level of appeals is handled by the Qualified Independent Contractor (QIC), which is separate from Palmetto GBA. Information about the QIC is included on your Redetermination decision letter from Railroad Medicare.
• 3rd level – Administrative Law Judge (ALJ) – If you don’t agree with the QIC’s decision, you can request a hearing by the ALJ. You have to file a request for an ALJ hearing within 60 days from the date of your reconsideration letter. The bill you are appealing must be more than $140.00.
• 4th level – Medicare Appeals Council – If you disagree with the ALJ’s decision, you have 60 days after you get your decision to ask for a review by the Medicare Appeals Council.
• 5th level – Review by a Federal District Court– Follow the directions in the Medicare Appeals Council decision if you’d like to request a review by a Federal district court. The bill you are appealing must be more than $1,430.00.
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