Description
Medical documentation for ambulance services will be reviewed to determine the Medicare defined conditions have been met for payment.
Affected Code(s)
A0426, A0428, 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. Medicare Program Integrity Manual, Chapter 3- Verifying Potential Errors and Taking Corrective Actions, §§3.1- 3.6.6
8. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1861(s)(7)- Medical and Other Health Services
9. Social Security Act (SSA), Title XVIII- Health Insurance for the Aged and Disabled, Section 1834(l) (10)- (16)- Establishment of Fee Schedule for Ambulance Services
10. 42 CFR 410.40- Coverage of ambulance services, (a) Definitions; (b) Basic rules; (c) Levels of service; (e) Medical necessity requirements
11. 42 CFR 410.41- Requirements for ambulance providers and suppliers, (c) Billing and reporting requirements
12. 42 CFR 414.605 Definitions
13. 42 CFR 414.610 Basis of Payment
14. 42 CFR 424.36- Signature Requirements
15. 42 CFR 424.37 Evidence of Authority to Sign on behalf of the Beneficiary.
16. 42 CFR §424.5- Basic Conditions, (a)(6) Sufficient Information
17. Medicare Benefit Policy Manual, Chapter 10- Ambulance Services, §10- Ambulance Service, §20- Coverage Guidelines for Ambulance Service Claims, §30.1.1- Ground Ambulance Services
18. Medicare Claims Processing Manual, Chapter 15- Ambulance, §10.2 – Summary of the Benefit
19. HCPCS Level II Codebook