RELATES TO: KRS 205.520
STATUTORY AUTHORITY: KRS 194A.030(2), 194A.050(1), 205.520(3), 42 C.F.R. 431.53, 440.170, 42 U.S.C. 1396d, EO 2004-726
NECESSITY, FUNCTION, AND CONFORMITY: EO 2004-726, effective July 9, 2004, reorganized the Cabinet for Health Services and placed the Department for Medicaid Services and the Medicaid Program under the Cabinet for Health and Family Services. The Cabinet for Health and Family Services, Department for Medicaid Services has responsibility to administer the Medicaid Program. KRS 205.520(3) authorizes the cabinet, by administrative regulation, to comply with any requirement that may be imposed, or opportunity presented, by federal law for the provision of medical assistance to Kentucky's indigent citizenry. This administrative regulation establishes the provisions relating to coverage of ambulance transportation services to access a medical service for which payment shall be made by the Medicaid Program.
Section 1. Definitions. (1) "Ambulance transportation" means ground or air transportation provided at advanced life support level or basic life support level by a carrier licensed by the Kentucky Board of Emergency Medical Services.
(2) "Appropriate medical facility or provider" means a local medical provider other than an emergency room of a hospital who can provide necessary emergency care if a hospital emergency room is not located within the medical service area.
(3) "Attending physician" means a physician who provided medical care to the recipient at the time ambulance transportation was needed and may include:
(a) The physician that the ambulance provider was in contact with to determine where the recipient needed to be transported for immediate care;
(b) The physician at the facility that treated the patient on arrival from the ambulance transportation;
(c) The physician at the care facility that recommended the recipient be transported to another facility for care not available at the original care facility; or
(d) The physician at a nursing facility that determined that the recipient needed to be transported to a hospital.
(4) "Department" means the Department for Medicaid Services or its designated agent.
(5) "Medical service area" means a recipient's county of residence or a contiguous county.
(6) "Medically necessary" or "medical necessity" means a covered benefit is determined to be needed in accordance with 907 KAR 3:130.
(7) "Other medical professional" means a physician assistant, advanced registered nurse practitioner, licensed nurse, or qualified mental health professional who is approved to practice by the appropriate professional licensure board.
Section 2. Conditions of Participation. (1) A participating ambulance transportation provider shall comply with the terms and conditions established in:
(a) 907 KAR 1:671, Conditions of Medicaid provider participation; withholding overpayments, appeals process and sanctions; and
(b) 907 KAR 1:672, Provider enrollment, disclosure and documentation for Medicaid participation.
(2) In accordance with 907 KAR 1:005, a participating ambulance transportation provider shall:
(a) Not bill the recipient and the department for the same service; and
(b) Bill a third-party payer prior to billing Medicaid for a covered service.
(3) A participating ambulance transportation provider shall comply with the requirements regarding the confidentiality of personal records as mandated by 42 U.S.C. 1320d and 45 C.F.R. Parts 160 and 164.
Section 3. Emergency Ambulance Services. (1) An emergency ambulance service shall be covered to and from a hospital emergency room in the medical service area if the:
(a) Service is medically necessary; and
(b) Documentation is maintained for postpayment review to indicate immediate emergency medical attention was provided in the emergency room.
(2) An emergency ambulance service to an appropriate medical facility or provider other than a hospital emergency room shall require documentation from the attending physician of:
(a) Medical necessity;
(b) Absence of a hospital emergency room in the medical service area; and
(c) Delivery of emergency care to the patient.
Section 4. Nonemergency Ambulance Services. (1) A nonemergency ambulance service to a provider within the medical service area shall be covered if:
(a) The recipient's medical condition warrants transport by stretcher;
(b) The recipient is traveling to or from a Medicaid-covered service, exclusive of a pharmacy service; and
(c) The service is the least expensive available transportation for the recipient's needs.
(2) A nonemergency ambulance service provided outside the medical service area shall be covered if:
(a) The criteria specified in subsection (1) of this section are satisfied;
(b) The medical service required by the recipient is not available in the medical service area; and
(c) The recipient is referred by a physician.
Section 5. Documentation Required for Determination of Coverage. The necessity for an ambulance transportation service shall be:
(1) Determined by the department; and
(2) Based upon a statement of medical necessity by an attending physician which shall:
(a) Be maintained on file by the transportation provider for a period of five (5) years; and
(b) Include the following information:
1. Verification by the provider of the:
a. Date of ambulance service;
b. Patient's name;
c. Patient's Medicaid identification number;
d. Patient's address;
e. Origin of ambulance service; and
f. Destination of ambulance service; and
2. A signed and dated statement by the attending physician, or other medical professional carrying out the orders of the attending physician, which verifies the patient's diagnosis and whether or not the patient:
a. Received treatment in an outpatient setting following transport;
b. Required admission to the hospital following transport;
c. Transferred from one (1) medical facility to another;
d. Was confined to bed before and after transport;
e. Required movement by stretcher; or
f. Had a medical condition which contraindicated transportation by means other than an ambulance.
Section 6. Appeal Rights. (1) An appeal of a department decision regarding a Medicaid recipient based upon an application of this administrative regulation shall be in accordance with 907 KAR 1:563.
(2) An appeal of a department decision regarding Medicaid eligibility of an individual shall be in accordance with 907 KAR 1:560.
(3) An appeal of a department decision regarding a Medicaid provider based upon an application of this administrative regulation shall be in accordance with 907 KAR 1:671. (Recodified from 904 KAR 1:060, 5-2-86; Am. 17 Ky.R. 1879; eff. 12-18-90; 22 Ky.R. 2497; eff. 8-21-96; 26 Ky.R. 658; 1184; 1421; eff. 1-12-2000; 30 Ky.R. 450; 878; eff. 10-31-03.)