Description
Specialty care transport (SCT) is the interfacility transportation of a critically injured or ill beneficiary by a ground ambulance vehicle. SCT is necessary when a beneficiary's condition requires ongoing care that must be furnished by one or more health professionals in an appropriate specialty area. Medical documentation for SCT will be reviewed to determine the Medicare defined conditions have been met for payment.
Affected Code(s)
A0434, A0425
Applicable Policy References
1. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1862(a)(1)(A)- Exclusions from Coverage and Medicare as a Secondary Payer
2. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1833(e)- Payment of Benefits
3. 42 CFR §405.929- Post-Payment Review
4. 42 CFR §405.930- Failure to Respond to Additional Documentation Request
5. 42 CFR §405.980- Reopening of Initial Determinations, Redeterminations, Reconsiderations, Decisions, and Reviews, (b)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Initiated by a Contractor; and (c)- Timeframes and Requirements for Reopening Initial Determinations and Redeterminations Requested by a Party
6. 42 CFR §405.986- Good Cause for Reopening
7. 42 CFR 410.40- Coverage of ambulance services, (a) Definitions, (c) Levels of service, and (e)(1) and (3) Medical necessity requirements
8. 42 CFR §410.41- Requirements for ambulance providers and suppliers, (c) Billing and reporting requirements.
9. 42 CFR §414.605 Definitions
10. 42 CFR §414.610 Basis of Payment
11. 42 CFR §424.36- Signature Requirements
12. 42 CFR §424.37- Evidence of Authority to Sign In on behalf of the Beneficiary
13. 42 CFR §424.5- Basic Conditions, (a)(6) Sufficient Information
14. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
15. Medicare Benefit Policy Manual (MBPM), Chapter 10 Ambulance Services, §10 Ambulance Service; §20 Coverage Guidelines for Ambulance Service Claims; §30.1.1 Ground Ambulance Services
16. Medicare Claims Processing Manual, Chapter 15 Ambulance, §10.2 Summary of the Benefit; §30 General Billing Guidelines, (A) Modifiers Specific to Ambulance Service Claims and (B) HCPCS Codes
17. HCPCS Level II Codebook