NHIC: How to Prevent Ambulance Claim Denials

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  • March 11, 2011
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If your practice is having trouble getting ambulance claims paid, perhaps it’s something you said, or didn’t say. In a provider education article, NHIC, Corp., Part B Medicare administrative contractor (MAC) for jurisdiction 14, says the key to getting an ambulance claim paid is to establish medical necessity; and to do that “it is essential that providers supply claims information that will substantiate: (1) the patient’s need to be transported by ambulance, versus other forms of transportation, and (2) the level of service utilized.”

To accomplish this, NHIC recommends providers make use of the narrative field (item 19) on the CMS-1500 claim form or the EMC field NTE02 to provide additional information that supports the medical necessity of the ambulance transport. For example, you might note:

  • The patient’s condition
  • Special circumstances for additional mileage
  • Information to support Specialty Care Transports (SCT) or ALS2 transports
  • Facility-to-facility transports

Choose your words carefully, though. NHIC (and probably all MACs) consider vague statements like the following insufficient evidence of medical necessity:

  • End stage renal disease (ESRD) transport
  • Stretcher required
  • Non-ambulatory
  • Patient admitted
  • Discharged to home or nursing home
  • Discharged to rehab

Statement examples NHIC says are acceptable include:

  • Methicillin-resistant Staphylococcus aureus (MRSA) precautions
  • Non-self administered oxygen
  • Alzheimer’s special care
  • Restrained for protection of self and others
  • Agitated, combative
  • Section 12 (psych)
  • Closest appropriate facility
  • Services not available at sending facility

For example, if you put down something like “non-ambulatory,” additionally state why the patient was non-ambulatory, such as “Non-ambulatory due to epileptic episode.” In other words, make sure your claims include all the who, what, where, when, and why information your contractor requires and the rate at which your claims are paid will greatly improve.

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