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Home My WebLink AboutAgenda - 06-15-2021; 8-r - Medicaid Transformation - Public Ambulance Providers (PAPs) Contracts with Public Healthcare Providers (PHPs)-Managed Care Organizations (MCOs) 1 ORANGE COUNTY BOARD OF COMMISSIONERS ACTION AGENDA ITEM ABSTRACT Meeting Date: June 15, 2021 Action Agenda Item No. 8-r SUBJECT: Medicaid Transformation - Public Ambulance Providers (PAPs) Contracts with Public Healthcare Providers (PHPs)/Managed Care Organizations (MCOs) DEPARTMENT: Emergency Services ATTACHMENT(S): INFORMATION CONTACT: DHB Managed Care PHP Ambulance Kirby Saunders, 919-245-6123 Provider Fee Schedule Kim Woodward, 919-245-6133 NC Medicaid Clinical Coverage Policy 15- Ambulance Services North Carolina's Transformation to Medicaid Managed Care Fact Sheet PURPOSE: To approve entering into agreements with the five (5) Managed Health Care Organizations in order to be eligible for direct payments for Medicaid transports by Orange County Emergency Medical Services (EMS). BACKGROUND: The NC Department of Health and Human Services (DHHS) will transition most beneficiaries to NC Medicaid Managed Care statewide on July 1, 2021. In order to be eligible, the County must enter into agreements by July 1, 2021 with the five (5) Managed Health Care Organizations for direct payments for Medicaid transports by EMS. North Carolina has proposed a qualified directed payment to Public Ambulance Providers (PAPs) to approximate the costs of covered services which PAPs incur in serving Medicaid and NC Health Choice beneficiaries. Enabling state legislation, Session Law 2015-245 https://www.ncleg.gov/enacted leg islation/sessionlaws/htm1/2015-2016/s12015-245.htm1, requires PAPs to become in-network providers with each of the Public Healthcare Providers (PHPs)/Managed Care Organizations (MCOs) companies. Failing to contract with each individual provider may result in significant loss of revenue for Orange County as compared to existing and proposed Medicaid fee schedules. As such, Orange County Emergency Services is required by state legislation to contract with each of the five (5) MCOs (AmeriHealth Caritas, Blue Cross NC, Carolina Complete Health, United Health, and WellCare) before July 1, 2021. The state has established cost-based rates for each Public Ambulance Provider that determined a minimum fee schedule that will serve as a rate floor (fee schedule) in managed care. The rates are subject to approval by the Center for Medicare and Medicaid Services. The draft rate schedule and the Public Ambulance Provider Addendum are provided as attachments. The Public Ambulance Provider Addendum has been included in each of the contracts. Based on the 2 proposed fee schedule and the County's payor mix, staff is anticipating a positive impact on revenue. Additionally, there may be the potential for additional revenue sources associated with expanded program in the future. NC EMS providers will be expected to contract with the PHPs in order to receive payment for services provided to these Medicaid recipients. Claims will be filed to the PHP for eligible Medicaid recipients rather than directly to NC Medicaid. Infocrossing, LLC has been named the Provider Data Contractor, whose responsibilities will include credentialing of Medicaid-enrolled providers and sharing the information with the PHPs. The goal of the Provider Data Contractor will ensure a consistent process of enrollment. Under the managed care program, the Department will mandate that the PHP maintain a certain level of payment by establishing a rate floor, or minimum payment of 100% of the Medicaid fee for-service rates Orange County Emergency Services has been meeting with the North Carolina Department of Health and Human Services (NCDHHS), PHPs/MCOs, and other PAPs for approximately 18 months to determine the contract processes. The new rate is expected to go live on July 1, 2021 . The Orange County floor rate is $1,067.92 as identified in the latest rate schedule provided by NCDHHS on March 31, 2021. This source accounts for approximately 27% of EMS fees, or roughly $700,000 a year in revenue for Orange County. The contracts are being finalized and may be modified before the July 1, 2021 deadline. Any substantial new information as determined by the County Attorney will be provided to the BOCC. Staff requests that the Board approve entering into contracts with Public Healthcare Providers (PHPs)/Managed Care Organizations (MCOs)for Orange County Emergency Services to become an in-network provider for their members/covered persons and authorize the County Manager to execute the contracts and any addendum to the contracts. FINANCIAL IMPACT: Staff projects $700,000 in expected revenue for Orange County. SOCIAL JUSTICE IMPACT: The following Orange County Social Justice Goal impact is applicable to this item: • GOAL: CREATE A SAFE COMMUNITY The reduction of risks from vehicle/traffic accidents, childhood and senior injuries, gang activity, substance abuse and domestic violence. ENVIRONMENTAL IMPACT: There is no Orange County Environmental Responsibility Goal impact associated with this item. RECOMMENDATION(S): The Manager recommends that the Board approve entering into the five (5) contracts with the identified MCOs and authorize the County Manager to execute the contracts and addendums. 3 PHP Managed Care Ambulance Fee Schedule Rates Effective as of 7/1/2021 North Carolina has proposed a qualified directed payment to public ambulance providers(PAPS)to approximate 100%of the costs of covered services which PAPs incur in serving Medicaid and NC Health Choice beneficiaries. The State has established cost-based rates for each PAP that determined the minimum fee schedule below that shall serve as a rate floor in managed care.The table below represents draft rates effective 7/1/2021 per ambulance transport.All rates are subject to approval by the Center for Medicare and Medicaid Services. Taxonomies: 341600000X, 3416A0800X, 3416L0300X, 3416SO30OX Billable Ground Transport HCPCS Codes=A0426,A0427,A0428,A0429,A0433,T2003 Billable Air Transport HCPCS Codes =A0430,A0431 No separate reimbursement for mileage codes for Public Ambulance Providers Guide and the Medicaid and Health Choice Clinical Coverage Policies on the NC Medicaid Web site. Air Transport Ground Transport Medicaid/ Medicaid/NCHC NCHC Rate Per Public Ambulance Provider Name NPI Number Rate Per Trip Trip Effective Date End Date Alamance County EMS 1952406779 $ 500.63 N/A 7/1/2021 6/30/2022 Alexander County EMS 1568419273 $ 1,016.01 N/A 7/1/2021 6/30/2022 Allegheny County EMS 1336353317 $ 892.98 N/A 7/1/2021 6/30/2022 Anson County EMS 1770530123 $ 725.99 N/A 7/1/2021 6/30/2022 Atlantic Beach EMS(Town of) 1437106044 $ 1,651.26 N/A 7/1/2021 6/30/2022 Avery County EMS 1144213778 $ 937.84 N/A 7/1/2021 6/30/2022 Beaufort County EMS 1255780136 $ 2,159.17 N/A 7/1/2021 6/30/2022 Bertie County EMS 1356762306 $ 1,073.91 N/A 7/1/2021 6/30/2022 Bladen County EMS 1407802861 $ 547.75 N/A 7/1/2021 6/30/2022 Brunswick County EMS 1831146471 $ 958.15 N/A 7/1/2021 6/30/2022 Buncombe County EMS 1073574786 $ 614.47 N/A 7/1/2021 6/30/2022 Burke County EMS 1538291760 $ 669.88 N/A 7/1/2021 6/30/2022 Cabarrus County EMS 1609855543 $ 681.25 N/A 7/1/2021 6/30/2022 Caldwell County EMS 1639188162 $ 809.92 N/A 7/1/2021 6/30/2022 Caswell County EMS 1356378855 $ 742.36 N/A 7/1/2021 6/30/2022 Catawba County EMS 1790732550 $ 609.49 N/A 7/1/2021 6/30/2022 Cherokee County EMS 1386691152 $ 1,305.32 N/A 7/1/2021 6/30/2022 Chowan County EMS 1568544179 $ 657.26 N/A 7/1/2021 6/30/2022 Clay County EMS 1063459907 $ 1,120.83 N/A 7/1/2021 6/30/2022 Cleveland County CMS 1093752818 $ 1,099.08 N/A 7/1/2021 6/30/2022 Craven County EMS 1629015516 $ 1,062.80 N/A 7/1/2021 6/30/2022 Currituck County EMS 1265479497 $ 3,103.30 N/A 7/1/2021 6/30/2022 Dare County EMS 1144223330 $ 2,330.02 N/A 7/1/2021 6/30/2022 Davidson County EMS 1205969292 $ 610.67 N/A 7/1/2021 6/30/2022 Davie County EMS 1790728319 $ 907.10 N/A 7/1/2021 6/30/2022 Duplin County EMS 1508919069 $ 947.86 N/A 7/1/2021 6/30/2022 Durham County EMS 1437159613 $ 774.98 N/A 7/1/2021 6/30/2022 Eastern Band Cherokee 911 1134179161 $ 944.69 N/A 7/1/2021 6/30/2022 Edgecombe County EMS* 1972685584 $ 352.00 N/A 7/1/2021 6/30/2022 Forsyth County EMS 1043250350 $ 506.54 N/A 7/1/2021 6/30/2022 Franklin County 911 1942226501 $ 1,153.81 N/A 7/1/2021 6/30/2022 Gaston County EMS 1932258506 $ 588.59 N/A 7/1/2021 6/30/2022 Gates County EMS 1528444643 $ 546.60 N/A 7/1/2021 6/30/2022 Graham County EMS 1194741066 $ 1,012.31 N/A 7/1/2021 6/30/2022 Greene County EMS 1801833751 $ 570.83 N/A 7/1/2021 6/30/2022 Greenville City EMS 1851390553 $ 406.25 N/A 7/1/2021 6/30/2022 4 Guilford County EMS 1780622498 $ 511.87 N/A 7/1/2021 6/30/2022 Halifax County EMS 1730261348 $ 787.34 N/A 7/1/2021 6/30/2022 Harnett County EMS 1588626519 $ 958.90 N/A 7/1/2021 6/30/2022 Havelock EMS(Town of) 1508803313 $ 757.29 N/A 7/1/2021 6/30/2022 Haywood County EMS 1013949403 $ 702.22 N/A 7/1/2021 6/30/2022 Henderson County EMS 1891825782 $ 704.64 N/A 7/1/2021 6/30/2022 Hertford County EMS 1881637171 $ 541.52 N/A 7/1/2021 6/30/2022 Hyde County EMS 1417995309 $ 4,092.28 N/A 7/1/2021 6/30/2022 Iredell County EMS 1952349847 $ 732.13 N/A 7/1/2021 6/30/2022 Johnston County EMS 1114193844 $ 953.53 N/A 7/1/2021 6/30/2022 Jones County EMS 1184771479 $ 1,046.17 N/A 7/1/2021 6/30/2022 Lenoir County EMS 1508804568 $ 652.91 N/A 7/1/2021 6/30/2022 Lincoln County EMS 1144281858 $ 925.23 N/A 7/1/2021 6/30/2022 Macon County EMS 1851352561 $ 1,090.61 N/A 7/1/2021 6/30/2022 McDowell County EMS 1639382716 $ 610.37 N/A 7/1/2021 6/30/2022 Mecklenburg County EMS 1336226034 $ 567.87 N/A 7/1/2021 6/30/2022 Moore County EMS 1407964125 $ 610.45 N/A 7/1/2021 6/30/2022 Morehead City EMS 1598703290 $ 690.92 N/A 7/1/2021 6/30/2022 Nash County EMS 1326137530 $ 575.74 N/A 7/1/2021 6/30/2022 Newport EMS(Town of) 1578501490 $ 723.10 N/A 7/1/2021 6/30/2022 Northampton County EMS 1588868400 $ 1,027.66 N/A 7/1/2021 6/30/2022 Onslow County EMS 1720027147 $ 764.29 N/A 7/1/2021 6/30/2022 Orange County EMS 1629178629 $ 1,067.92 N/A 7/1/2021 6/30/2022 Pasquotank County EMS 1760445191 $ 586.82 N/A 7/1/2021 6/30/2022 Perquimans County EMS 1801895230 $ 1,385.30 N/A 7/1/2021 6/30/2022 Person County EMS 1972539278 $ 974.33 N/A 7/1/2021 6/30/2022 Pitt County EMS 1033155148 $ 703.65 N/A 7/1/2021 6/30/2022 Polk County EMS 1811925100 $ 558.83 N/A 7/1/2021 6/30/2022 Randolph County EMS 1619965274 $ 634.95 N/A 7/1/2021 6/30/2022 Robeson County EMS 1861468803 $ 405.77 N/A 7/1/2021 6/30/2022 Rockingham County EMS 1861489809 $ 538.92 N/A 7/1/2021 6/30/2022 Rowan County EMS 1437250347 $ 655.59 N/A 7/1/2021 6/30/2022 Rutherford County EMS 1225083413 $ 513.43 N/A 7/1/2021 6/30/2022 Sampson County EMS 1225076813 $ 760.26 N/A 7/1/2021 6/30/2022 Scotland County EMS 1114924644 $ 537.56 N/A 7/1/2021 6/30/2022 Stanly County EMS 1922150812 $ 744.01 N/A 7/1/2021 6/30/2022 Stokes County EMS 1952306862 $ 881.38 N/A 7/1/2021 6/30/2022 Surry County EMS 1306843107 $ 597.06 N/A 7/1/2021 6/30/2022 Swain County EMS 1275571630 $ 881.19 N/A 7/1/2021 6/30/2022 Transylvania County EMS 1972627057 $ 796.70 N/A 7/1/2021 6/30/2022 Union County EMS 1104913326 $ 790.38 N/A 7/1/2021 6/30/2022 Vance County EMS 1376530725 $ 526.46 N/A 7/1/2021 6/30/2022 Wake County EMS 1922098029 $ 629.95 N/A 7/1/2021 6/30/2022 Warren County EMS 1750463873 $ 1,311.80 N/A 7/1/2021 6/30/2022 Washington City EMS 1275515272 $ 956.65 N/A 7/1/2021 6/30/2022 Washington County EMS 1790821817 $ 552.59 N/A 7/1/2021 6/30/2022 Wayne County EMS 1154363380 $ 469.70 N/A 7/1/2021 6/30/2022 Wilkes County EMS 1669539458 $ 609.96 N/A 7/1/2021 6/30/2022 Williamston CMS(Town of) 1013955525 $ 454.71 N/A 7/1/2021 6/30/2022 Wilson County EMS 1932281540 $ 592.25 N/A 7/1/2021 6/30/2022 Yadkin County EMS 1083651434 $ 891.36 N/A 7/1/2021 6/30/2022 Cape Fear 1689786717 $ 434.72 N/A 7/1/2021 6/30/2022 Cape Fear Hoke 1487067062 $ 537.85 N/A 7/1/2021 6/30/2022 UNC Hospitals 1932208576 $ 2,600.73 $ 19,358.55 7/1/2021 6/30/2022 Carolinas Medical Center 1043313513 $ 1,102.09 $ 11,261.42 7/1/2021 6/30/2022 Vidant Medical 1669434023 $ 1,039.65 $ 7,378.83 7/1/2021 6/30/2022 5 NC Medicaid Medicaid and Health Choice Ambulance Services Clinical Coverage Policy No: 15 Effective Date: January 15, 2020 To all beneficiaries enrolled in a Prepaid Health Plan (PHP): for questions about benefits and services available on or after implementation,please contact your PHP. Table of Contents 1.0 Description of the Procedure,Product, or Service...........................................................................l 1.1 Definitions.......................................................................................................................... 1 1.1.1 Ground and Air Medical Ambulances................................................................... 1 1.1.2 Emergency Services............................................................................................... 1 1.1.2.1 Emergency Medical Condition..............................................................................1 1.1.2.2 Emergency and Immediate Responses...................................................................l 1.1.2.3 Emergency Ground Transport...............................................................................2 1.1.2.4 Basic Life Support.................................................................................................2 1.1.2.5 Advanced Life Support..........................................................................................2 1.1.3 Non-emergency Medically Necessary Ambulance Transport...............................3 1.1.4 Air Medical Ambulance.........................................................................................3 1.1.5 Loaded Mileage.....................................................................................................3 1.1.6 Locality..................................................................................................................4 1.1.7 Nearest Appropriate Facility..................................................................................4 1.1.8 Round Trip and One-Way Trip..............................................................................4 1.1.9 Date of Service.......................................................................................................4 1.1.10 Point of Pick-up.....................................................................................................4 2.0 Eligibility Requirements..................................................................................................................4 2.1 Provisions............................................................................................................................4 2.1.1 General...................................................................................................................4 2.1.2 Specific..................................................................................................................5 2.2 Special Provisions...............................................................................................................5 2.2.1 EPSDT Special Provision: Exception to Policy Limitations for a Medicaid Beneficiary under 21 Years of Age.......................................................................5 2.2.2 EPSDT does not apply to NCHC beneficiaries.....................................................6 2.2.3 Health Choice Special Provision for a Health Choice Beneficiary age 6 through 18 years of age.......................................................................................................6 3.0 When the Procedure,Product, or Service Is Covered......................................................................6 3.1 General Criteria Covered....................................................................................................6 3.2 Specific Criteria Covered....................................................................................................7 3.2.1 Specific criteria covered by both Medicaid and NCHC........................................7 3.2.1.1 Air Medical Ambulance.........................................................................................7 3.2.1.2 Ambulance Transport of Deceased Beneficiaries..................................................7 3.2.1.3 Out-of-State(Non-Contiguous)Transport of Beneficiaries..................................7 3.2.1.4 Out-of-County Transport of Beneficiaries.............................................................8 3.2.1.5 Transport to Behavioral Health Crisis Centers......................................................8 3.2.2 Medicaid Additional Criteria Covered...................................................................8 3.2.2.1 Origin and Destination...........................................................................................8 3.2.2.2 Non-emergency Medically Necessary Ambulance Transport...............................9 3.2.2.3 Ambulance Services during Pregnancy...............................................................10 3.2.3 NCHC Additional Criteria Covered....................................................................10 20A 13 i 6 NC Medicaid Medicaid and Health Choice Ambulance Services Clinical Coverage Policy No: 15 Effective Date: January 15, 2020 3.2.3.1 Origin and Destination......................................................................................... 10 4.0 When the Procedure, Product, or Service Is Not Covered.............................................................11 4.1 General Criteria Not Covered...........................................................................................11 4.2 Specific Criteria Not Covered...........................................................................................11 4.2.1 Specific Criteria Not Covered by both Medicaid and NCHC..............................11 4.2.1.1 Nearest Appropriate Facility................................................................................11 4.2.1.2 Transport of Deceased Beneficiaries...................................................................11 4.2.1.3 Air Medical Ambulance.......................................................................................11 4.2.1.4 Other Non-covered Ambulance Services.............................................................11 4.2.2 Medicaid Additional Criteria Not Covered..........................................................12 4.2.2.1 Maternity Transport.............................................................................................12 4.2.2.2 Nursing Facility Non-Ambulance Transportation...............................................12 4.2.3 NCHC Additional Criteria Not Covered..............................................................12 5.0 Requirements for and Limitations on Coverage............................................................................12 5.1 Prior Approval..................................................................................................................13 5.2 Prior Approval Requirements...........................................................................................13 5.2.1 General.................................................................................................................13 5.2.2 Specific................................................................................................................13 5.3 Limitations or Requirements.............................................................................................14 6.0 Provider(s)Eligible to Bill for the Procedure,Product,or Service ...............................................14 6.1 Provider Qualifications and Occupational Licensing Entity Regulations.........................14 6.2 Provider Certifications......................................................................................................14 6.3 Licensure and Vehicles.....................................................................................................14 6.4 In-State Ambulance Service Requirements......................................................................14 6.5 Out-of-State Ambulance Service Requirements...............................................................14 7.0 Additional Requirements...............................................................................................................15 7.1 Compliance.......................................................................................................................15 7.2 Call Reports......................................................................................................................15 7.3 Physician Certification and Order for Non-Emergency Medicaid Ambulance Services..16 7.3.1 Non-Emergency, Scheduled,Repetitive Ambulance Services............................16 7.3.2 Non-Emergency Ambulance Services That Are Either Unscheduled or That Are Scheduled on a Non-Repetitive Basis..................................................................16 8.0 Policy Implementation and History...............................................................................................17 Attachment A: Claims-Related Information...............................................................................................18 A. Claim Type .......................................................................................................................18 B. International Classification of Diseases and Related Health Problems,Tenth Revisions, Clinical Modification(ICD-IO-CM) and Procedural Coding System(PCS) ...................18 C. Code(s)..............................................................................................................................18 D. Modifiers...........................................................................................................................19 E. Billing Units......................................................................................................................20 F. Place of Service................................................................................................................20 G. Co-payments.....................................................................................................................20 H. Reimbursement.................................................................................................................20 20A13 ii 7 NC Medicaid Medicaid and Health Choice Ambulance Services Clinical Coverage Policy No: 15 Effective Date: January 15, 2020 Related Clinical Coverage Policies Refer to htips://medicaid.ncdhhs.gov/for the related coverage policies listed below: 1E-7,Family Planning Services 2A-3, Out-of-State Services Information Refer to the following web sites for information: NC Medicaid Provider Services: https://medicaid.ncdhhs.gov/ OEMS Website: https://www.ncdhhs.gov/divisions/dhsr Provider Policies,Manuals and Guidelines: https://www.nctracks.nc.gov/content/public/providers/provider-manuals.html 1.0 Description of the Procedure, Product, or Service Ambulance services provide medically necessary treatment for NC Medicaid Program or NC Health Choice beneficiaries. Transport is provided only if the beneficiary's medical condition is such that the use of any other means of transportation is contraindicated. Ambulance services include emergency and non-emergency ambulance transport via ground and air medical ambulance for a Medicaid beneficiary. Ambulance services include only emergency transport via ground and air medical ambulance for a NCHC beneficiary. Refer to Subsection 4.0. 1.1 Definitions 1.1.1 Ground and Air Medical Ambulances A ground ambulance is the same as defined in l0A NCAC 13P .0102(29). In this policy, ambulance transport by either land or water vehicles may be referred to as"ground transportation."Vehicle and equipment requirements are located at l0A NCAC 13P .0207, .0208, and.0210. An air medical ambulance is the same as defined in l0A NCAC 13P .0102(5). Vehicle and equipment requirements are located at 10A NCAC 13P .0209. 1.1.2 Emergency Services 1.1.2.1 Emergency Medical Condition An emergency medical condition is defined in 42 C.F.R. 489.24(b). 1.1.2.2 Emergency and Immediate Responses An emergency response means responding immediately at the Basic Life Support(BLS) or Advanced Life Support Level 1 (ALS1) service to a 911 call or the equivalent in areas without a 911 call system. An immediate response is one in which the ambulance service begins as quickly as possible to take the steps necessary to respond to a 911 call. CPT codes, descriptors, and other data only are copyright 2018 American Medical Association. All rights reserved.Applicable FARS/DFARS apply. 20A13 1 8 NC Medicaid Medicaid and Health Choice Ambulance Services Clinical Coverage Policy No: 15 Effective Date:January 15,2020 1.1.2.3 Emergency Ground Transport Emergency ground transport is medically necessary ground transportation to the nearest appropriate facility where prompt medical services are provided in an emergency situation such as accident, acute illness, or injury. Emergency ground transport includes both BLS and ALS services. 1.1.2.4 Basic Life Support BLS is transportation by a ground ambulance vehicle and the provision of medically necessary supplies and services,including BLS ambulance services as defined by the State Office of Emergency Medical Services(GEMS). The ambulance shall be staffed by an individual who is credentialed in accordance with 1O NCAC 13P .0502 and G.S. 131E-159 as an Emergency Medical Technician (EMT). 1.1.2.5 Advanced Life Support ALS services include BLS plus invasive procedures and techniques provided by Emergency Medical Technicians—Intermediate(EMT-1) or Emergency Medical Technicians—Paramedic (EMT—P)who are credentialed in accordance with l0A NCAC 13P .0502. An EMT—I is credentialed to perform essential advanced techniques and to administer a limited number of medications in addition to the skills of the EMT. An EMT—P is credentialed to administer additional medications and interventions in addition to the skills of the EMT and EMT-I. An ALS assessment must be a medically necessary procedure performed by an ALS crew as part of an emergency response and necessary because the beneficiary's reported condition at the time of dispatch is such that only an ALS crew is qualified to perform the assessment.An ALS assessment does not necessarily result in a determination that the beneficiary requires an ALS level of service. An ALS intervention is a procedure that is,in accordance with state and local laws,rendered by ALS personnel. If local protocols require an ALS response for all calls,N.C. Medicaid only covers the level of service actually provided.ALS level of service must include ALS assessment,ALS intervention, or both,and then only when the service is medically necessary. ALS Level 1 (ALS 1) is the transportation by ground ambulance vehicle and the provision of an ALS assessment or at least one ALS intervention. ALS Level 2 (ALS2) is the transportation by ground ambulance vehicle and the provision of medically necessary supplies and services, including at least one of the following: a. At least three separate administrations of one or more medications by intravenous push or bolus or by continuous infusion, excluding 20A 13 2 9 NC Medicaid Medicaid and Health Choice Ambulance Services Clinical Coverage Policy No: 15 Effective Date:January 15,2020 crystalloid,hypotonic,isotonic, and hypertonic solutions (Dextrose,Normal Saline, or Ringer's Lactate); or b. At least one of the ALS2 procedures listed below: 1. Manual defibrillation or cardioversion; 2. Cardiac pacing; 3. Endotracheal intubation insertion; 4. Central venous line; 5. Intraosseous line; 6. Chest decompression; 7. Surgical airway; 8. 12 Lead electrocardiogram(ECG)for Segment Elevation Myocardial Infarction[STEMI]; 9. Continuous Positive Airway Pressure (CPAP); 10. Ventilator Operation; or 11. Femoral Line. 1.1.3 Non-emergency Medically Necessary Ambulance Transport Non-emergency ambulance transport is a medically necessary transport for a Medicaid beneficiary to obtain medical services that cannot be provided when needed at the beneficiary's location, such as computed tomography(CT) scans, magnetic resonance imaging(MRI), endoscopies,radiation therapy, and dialysis. 1.1.4 Air Medical Ambulance Air medical ambulance applies to both rotary-wing and fixed-wing aircraft. Rotary-wing air medical ambulance is transport by a helicopter that has been inspected and issued a permit by the State OEMS as a rotary-wing ambulance, and the provision of medically necessary supplies and services. Fixed-wing air medical ambulance is transport by a fixed-wing aircraft that has been inspected and issued a permit by the State OEMS as a fixed-wing air medical ambulance, and the provision of medically necessary supplies and services. Vehicle and equipment requirements are located at 1 O NCAC 13P .0209. 1.1.5 Loaded Mileage Loaded mileage is the number of miles for which the beneficiary is transported in the ambulance vehicle. For air medical ambulance(fixed wing and rotary wing),the point of origin includes-the beneficiary's loading point and runway taxiing until the beneficiary is offloaded from the air medical ambulance. Air mileage is based on loaded miles flown, as expressed in statute miles,and is reimbursable. For ground ambulance,loaded mileage is from the point of origin to the nearest appropriate facility. Mileage to a facility that does not meet this criterion is not covered. Ground ambulance loaded mileage is reimbursable only for out-of- county transport. In-county loaded ground mileage is not reimbursable. Out of county transport is a transport by ambulance in which the final destination of the beneficiary is outside the limits of the county in which the transport originated. 20A13 3 10 NC Medicaid Medicaid and Health Choice Ambulance Services Clinical Coverage Policy No: 15 Effective Date:January 15,2020 1.1.6 Locality Locality means the service area surrounding the institution to which beneficiaries normally travel or are expected to travel to receive hospital or skilled nursing services. If two or more facilities that meet the destination requirements can treat the beneficiary appropriately, and the locality of each facility encompasses the place where the ambulance transportation of the beneficiary began,then the out of county mileage(if applicable)to any one of the facilities to which the beneficiary is taken is covered. 1.1.7 Nearest Appropriate Facility The nearest appropriate facility for emergency transport is the nearest institution or medical facility that is capable,under federal and state laws, of furnishing the required type of care for the beneficiary's illness or injury. 1.1.8 Round Trip and One-Way Trip A round trip is non-emergency transportation by ambulance from the point of pickup to destination and return to point of pickup. The ambulance remains in the vicinity of the destination, does not return to base, and does not respond to other calls for transport. This service is covered for Medicaid beneficiaries only. Refer to Subsection 4.0. A one-way trip is emergency or non-emergency transportation from point of pickup to destination. Delivery of the beneficiary at the destination discharges the ambulance provider's responsibility. The ambulance service is then available to transport other beneficiaries. 1.1.9 Date of Service The date of service of an ambulance service is the date that the loaded ambulance vehicle departs the point of pick-up. In the case of a ground transport,if the beneficiary is pronounced dead after the vehicle is dispatched but before the (now deceased)beneficiary is loaded into the vehicle,the date of service is the date of the vehicle's dispatch. 1.1.10 Point of Pick-up The point of pick-up is the location of the beneficiary at the time placed on board the ambulance. 2.0 Eligibility Requirements 2.1 Provisions 2.1.1 General (The term "General"found throughout this policy applies to all Medicaid and NCHC policies) a. An eligible beneficiary shall be enrolled in either: 1. the NC Medicaid Program; or 2. the NC Health Choice Program on the date of service and shall meet the criteria in Section 3.0 of this policy. 20A13 4 11 NC Medicaid Medicaid and Health Choice Ambulance Services Clinical Coverage Policy No: 15 Effective Date:January 15,2020 b. Provider(s) shall verify each Medicaid or NCHC beneficiary's eligibility each time a service is rendered. c. The Medicaid beneficiary may have service restrictions due to their eligibility category that would make them ineligible for this service. d. Following is only one of the eligibility and other requirements for participation in the NCHC Program under GS 108A-70.21(a): Children must be between the ages of 6 through 18. 2.1.2 Specific a. Medicaid None Apply. b. NCHC None Apply. 2.2 Special Provisions 2.2.1 EPSDT Special Provision: Exception to Policy Limitations for a Medicaid Beneficiary under 21 Years of Age a. 42 U.S.C. § 1396d(r) [1905(r)of the Social Security Act] Early and Periodic Screening,Diagnostic, and Treatment(EPSDT)is a federal Medicaid requirement that requires the state Medicaid agency to cover services,products, or procedures for Medicaid beneficiary under 21 years of age if the service is medically necessary health care to correct or ameliorate a defect,physical or mental illness, or a condition [health problem] identified through a screening examination" (includes any evaluation by a physician or other licensed clinician). This means EPSDT covers most of the medical or remedial care a child needs to improve or maintain his or her health in the best condition possible, compensate for a health problem,prevent it from worsening, or prevent the development of additional health problems. Medically necessary services will be provided in the most economic mode, as long as the treatment made available is similarly efficacious to the service requested by the beneficiary's physician,therapist,or other licensed practitioner; the determination process does not delay the delivery of the needed service; and the determination does not limit the beneficiary's right to a free choice of providers. EPSDT does not require the state Medicaid agency to provide any service, product or procedure: 1. that is unsafe,ineffective, or experimental or investigational. 2. that is not medical in nature or not generally recognized as an accepted method of medical practice or treatment. Service limitations on scope, amount, duration, frequency, location of service, and other specific criteria described in clinical coverage policies may be exceeded or may not apply as long as the provider's documentation shows that the requested service is medically necessary"to correct or ameliorate a defect,physical or mental illness, or a condition" [health problem]; that is, provider documentation shows how the service,product, or procedure meets 20A 13 5 12 NC Medicaid Medicaid and Health Choice Ambulance Services Clinical Coverage Policy No: 15 Effective Date:January 15,2020 all EPSDT criteria,including to correct or improve or maintain the beneficiary's health in the best condition possible, compensate for a health problem,prevent it from worsening, or prevent the development of additional health problems. b. EPSDT and Prior Approval Requirements 1. If the service,product, or procedure requires prior approval,the fact that the beneficiary is under 21 years of age does NOT eliminate the requirement for prior approval. 2. IMPORTANT ADDITIONAL INFORMATION about EPSDT and prior approval is found in the NCTracks Provider Claims and Billing Assistance Guide, and on the EPSDT provider page. The Web addresses are specified below. NCTracks Provider Claims and Billing Assistance Guide: https://www.nctracks.nc.gov/content/public/providers/provider- manuals.html EPSDT provider page: https:Hmedicaid.ncdhhs.gov/ 2.2.2 EPSDT does not apply to NCHC beneficiaries 2.2.3 Health Choice Special Provision for a Health Choice Beneficiary age 6 through 18 years of age NC Medicaid shall deny the claim for coverage for an NCHC beneficiary who does not meet the criteria within Section 3.0 of this policy. Only services included under the NCHC State Plan and the NC Medicaid clinical coverage policies, service definitions, or billing codes are covered for an NCHC beneficiary. 3.0 When the Procedure, Product, or Service Is Covered Note:Refer to Subsection 2.2.1 regarding EPSDT Exception to Policy Limitations for a Medicaid Beneficiary under 21 Years of Age. 3.1 General Criteria Covered Medicaid and NCHC shall cover procedures,products,and services related to this policy when they are medically necessary, and: a. the procedure,product, or service is individualized, specific,and consistent with symptoms or confirmed diagnosis of the illness or injury under treatment, and not in excess of the beneficiary's needs; b. the procedure,product, or service can be safely furnished, and no equally effective and more conservative or less costly treatment is available statewide; and c. the procedure,product, or service is furnished in a manner not primarily intended for the convenience of the beneficiary,the beneficiary's caretaker, or the provider. 20A13 6 13 NC Medicaid Medicaid and Health Choice Ambulance Services Clinical Coverage Policy No: 15 Effective Date:January 15,2020 3.2 Specific Criteria Covered 3.2.1 Specific criteria covered by both Medicaid and NCHC 3.2.1.1 Air Medical Ambulance For air medical ambulance,the point of origin is the beneficiary's loading point and runway taxiing,until the beneficiary is offloaded from the air medical ambulance. Air medical ambulance is covered in any one of the following situations: a. the beneficiary's medical condition requires immediate and rapid ambulance transport that cannot be provided by ground ambulance; b. the point of pickup is inaccessible by ground vehicle; or c. the beneficiary's condition is such that the time needed to transport the beneficiary by land, or the instability of transport by land,to the nearest appropriate facility poses a threat to the beneficiary's survival or endangers the beneficiary's health. Some conditions requiring emergency air medical ambulance transportation are: a. intracranial bleeding requiring neurosurgical intervention; b. shock; c. major burns requiring treatment in a burn center; d. conditions requiring immediate treatment in a hyperbaric oxygen unit; e. multiple severe injuries; f. life-threatening trauma; g. ST Segment Elevation Myocardial Infarction(STEMI); and h. cardiovascular Accident(CVA). 3.2.1.2 Ambulance Transport of Deceased Beneficiaries Ambulance transport of a deceased beneficiary is covered in either one of the following situations: a. The beneficiary is pronounced dead by a legally authorized individual after the dispatch of the ambulance,but before the beneficiary is loaded on board the ambulance. The provider is reimbursed for the BLS base rate.No mileage is reimbursed. The date of service is the date of the dispatch of the ambulance. Use QL modifier,"Patient pronounced dead after ambulance called," on the claim; or b. The beneficiary is pronounced dead by a legally authorized individual after pick-up but prior to arrival at the receiving facility. The same reimbursement rules apply as if the beneficiary were alive. 3.2.1.3 Out-of-State (Non-Contiguous) Transport of Beneficiaries Hospitals, acute medical care, and ambulance services are out-of-state services when they are provided more than 40 miles outside of the N.C. border. 20A 13 7 14 NC Medicaid Medicaid and Health Choice Ambulance Services Clinical Coverage Policy No: 15 Effective Date:January 15,2020 Hospitals, acute medical care, and ambulance services provided within 40 miles of the N.C. border in the contiguous states of Georgia, South Carolina,Tennessee, and Virginia will be covered to the same extent and under the same conditions as services provided in North Carolina. These facilities and providers shall obtain Medicaid provider numbers. Contact NC Medicaid Provider Services(hgps:Hmedicaid.ncdhhs.gov/) for information on obtaining a Medicaid Provider number. Refer to clinical coverage policy,2A-3, Out-of-State Services, at htt2s:Hmedicaid.ncdhhs.gov/. 3.2.1.4 Out-of-County Transport of Beneficiaries Ground ambulance loaded mileage is reimbursable only for out-of- county transport. 3.2.1.5 Transport to Behavioral Health Crisis Centers NC Medicaid shall cover transport of Medicaid beneficiaries in behavioral health crisis to behavioral health clinics or alternative appropriate care locations when the following criteria are met: a. Emergency Medical Services(EMS)providers have received appropriate education in caring for beneficiaries in behavioral health crisis; b. EMS system has at least one partnership with a receiving facility that is able to provide care appropriate for those beneficiaries; and c. EMS systems shall be required to include in its EMS system plan a report on beneficiary experiences and outcomes in accordance with rules adopted by Department of Health and Human Services (DHHS),Division of Health Service Regulation(DHSR),Division of Health Benefits(DHB), and Office of Emergency Services (GEMS) (Session Law 2018-5 Section 11H.4(a)) 3.2.2 Medicaid Additional Criteria Covered 3.2.2.1 Origin and Destination Medicaid shall cover ambulance transports(that meet all other program requirements for coverage) only to the following destinations: d. hospital; e. critical access hospital; f. skilled nursing facility; g. adult care home; h. intermediate care facility for individuals with intellectual disabilities(ICF-IID); i. beneficiary's primary private residence; j. dialysis facility for end-stage renal disease if the beneficiary's condition requires ambulance services; k. transfer site(airport or helipad); 1. physician's office; 20A 13 8 15 NC Medicaid Medicaid and Health Choice Ambulance Services Clinical Coverage Policy No: 15 Effective Date:January 15,2020 1. Non-emergency transport to a physician's office shall meet the criteria in Subsection 3.2.2.2,Non-Emergency Medically Necessary Ambulance Transport. 2. Emergency transportation to a physician's office shall meet the following conditions: A. the beneficiary is en route to a hospital; B. there is medical need for a professional to stabilize the beneficiary's condition; and C. the ambulance continues the trip to the hospital immediately after stabilization. in. emergency transport from hospital to hospital is appropriate when the transferring facility does not have adequate facilities to provide needed care. Coverage is available only if the beneficiary is transferred to the nearest appropriate facility such as, transportation between burn centers,neonatal care centers,trauma units,primary cardiac intervention centers, and stroke centers; and n. emergency transport of a beneficiary residing in a nursing home shall meet medical necessity criteria for an emergency, and the services needed shall be unavailable at the facility. 3.2.2.2 Non-emergency Medically Necessary Ambulance Transport Non-emergency medically necessary ambulance transport is covered for Medicaid beneficiaries only in the following situations: a. medical necessity is indicated when the use of other means of transportation is medically contraindicated. This refers to beneficiaries whose medical condition requires transport by stretcher; b. the beneficiary is in need of medical services that cannot be provided in the place of residence; or c. return transportation is provided from a facility that can provide total care for every aspect of an injury or disease to a facility that has fewer resources to offer highly specialized care. Non-emergency medically necessary ambulance transport is appropriate in either of the following situations: a. the beneficiary is bed confined and it is documented that the beneficiary's medical condition is such that a stretcher is the only safe mode of transportation; or b. the beneficiary's medical condition,regardless of bed confinement, is such that transportation by ambulance is medically required. A beneficiary is bed confined when all of the following criteria are met. The beneficiary is: a. unable to get up from bed without assistance; b. unable to ambulate; and c. unable to sit in a chair or wheelchair. A provider shall move a bed-confined beneficiary by stretcher for: 20A13 9 16 NC Medicaid Medicaid and Health Choice Ambulance Services Clinical Coverage Policy No: 15 Effective Date:January 15,2020 a. contractures creating non-ambulatory status and the beneficiary cannot sit; b. immobility of lower extremities(spica cast, fixed hip joints)and unable to be moved by wheelchair; or c. return(back)transport, such as when a newborn is transported to a tertiary hospital for necessary care and services and,when stabilized, is transported back to the referring hospital to receive a lower level of services. 3.2.2.3 Ambulance Services during Pregnancy Ambulance services for pregnant beneficiaries must be medically necessary. Medical necessity may be present if one of the following conditions occur: a. Crowning; b. Hemorrhage; c. Preterm labor(prior to 37 weeks); d. Premature rupture of membranes; e. Abruptio placenta; f. Placenta Previa; g. Pre-eclampsia or Eclampsia; or h. Transport from a small hospital to tertiary hospital when beneficiary is in preterm labor. 3.2.3 NCHC Additional Criteria Covered 3.2.3.1 Origin and Destination NCHC shall cover only emergency ambulance transports that meet all other program requirements for coverage and only to the following destinations: a. Transportation to and from a hospital for inpatient care or outpatient emergency care; b. Transportation from a hospital to the nearest facility which is prepared to accept the beneficiary AND is able to provide needed service(s)which is(are)not available at the hospital where the beneficiary is presently confined; c. Critical access hospital; d. Transfer site(airport/helipad); e. Emergency transportation to a physician's office shall meet the following conditions: 1. the beneficiary is en route to a hospital; 2. there is medical need for a professional to stabilize the beneficiary's condition; and 3. the ambulance continues the trip to the hospital immediately after stabilization. f. Emergency transport from hospital to hospital is appropriate when the transferring facility does not have adequate facilities to provide needed care. Coverage is available only if the beneficiary is transferred to the nearest appropriate facility such as; transportation between burn centers,trauma units,primary cardiac intervention centers, and stroke centers. 20A13 10 17 NC Medicaid Medicaid and Health Choice Ambulance Services Clinical Coverage Policy No: 15 Effective Date:January 15,2020 g. Emergency transport to a behavioral health clinic or other appropriate location during a behavioral health crisis. 4.0 When the Procedure, Product, or Service Is Not Covered Note:Refer to Subsection 2.2.1 regarding EPSDT Exception to Policy Limitations for a Medicaid Beneficiary under 21 Years of Age. 4.1 General Criteria Not Covered Medicaid and NCHC shall not cover procedures,products, and services related to this policy when: a. the beneficiary does not meet the eligibility requirements listed in Section 2.0; b. the beneficiary does not meet the criteria listed in Section 3.0; c. the procedure,product, or service duplicates another provider's procedure,product, or service; or d. the procedure,product, or service is experimental, investigational, or part of a clinical trial. 4.2 Specific Criteria Not Covered 4.2.1 Specific Criteria Not Covered by both Medicaid and NCHC Medicaid and NCHC shall not cover the following: 4.2.1.1 Nearest Appropriate Facility a. The beneficiary is to be transferred to the nearest appropriate facility. Loaded mileage to a facility that does not meet this criterion is not reimbursed. b. The fact that a physician does or does not have staff privileges in a hospital is not a consideration in determining whether the hospital has appropriate facilities. c. A facility is not deemed appropriate or inappropriate based on a beneficiary's preference. 4.2.1.2 Transport of Deceased Beneficiaries Ambulance transport of a deceased beneficiary is not covered if the beneficiary is pronounced dead by a legally authorized individual before the ambulance is called. 4.2.1.3 Air Medical Ambulance Air medical ambulance transport to a facility that is not an acute-care hospital is not a covered service. 4.2.1.4 Other Non-covered Ambulance Services a. An ambulance is called and no treatment is needed. b. The ambulance responds to a false alarm call. c. The beneficiary refuses all medical services. d. Ambulance transport is for a medical service that is not a Medicaid or NCHC covered service. e. Commercial airline tickets are not reimbursable f. Airstrip fees are not covered. g. Charges for taxes(local, state, federal, etc.)are not covered. 20A13 11 18 NC Medicaid Medicaid and Health Choice Ambulance Services Clinical Coverage Policy No: 15 Effective Date:January 15,2020 h. Separate additional charges for nursing personnel who are employees of a facility or ambulance service are not covered. i. Waiting fees are not covered. j. Costs for oxygen and other items and supplies provided are included in the base rate and not separately reimbursable. k. Services other than those listed in Subsection 3.2 are not covered. 4.2.2 Medicaid Additional Criteria Not Covered 4.2.2.1 Maternity Transport Ambulance transport of beneficiaries with routine pregnancies is not covered. Beneficiaries without complications that would endanger the life of the mother,the child, or both do not meet medical necessity criteria. Beneficiaries with Medicaid coverage through Family Planning are not covered to receive ambulance services. 4.2.2.2 Nursing Facility Non-Ambulance Transportation Non-ambulance transportation of Medicaid-eligible beneficiaries to receive medical care that cannot be provided in the nursing facility is covered in the per diem that is reimbursed to the facility. The facility may contract with a service(including county-coordinated transportation systems)to provide transportation or may provide transportation services using its own vehicles. Note: The nursing facility cannot charge the beneficiary or the beneficiary's family for the cost of this transportation. 4.2.3 NCHC Additional Criteria Not Covered a. In addition to the specific criteria not covered in Subsection 4.2.1 of this policy,NCHC shall not cover prenatal or childbirth services. b. NCGS § 108A-70.21(b)"Except as otherwise provided for eligibility, fees, deductibles, copayments, and other cost sharing charges,health benefits coverage provided to children eligible under the Program shall be equivalent to coverage provided for dependents under North Carolina Medicaid Program except for the following: 1. No services for long-term care. 2. No nonemergency medical transportation. 3. No EPSDT. 4. Dental services shall be provided on a restricted basis in accordance with criteria adopted by the Department to implement this subsection. 5.0 Requirements for and Limitations on Coverage Note:Refer to Subsection 2.2.1 regarding EPSDT Exception to Policy Limitations for a Medicaid Beneficiary under 21 Years of Age. 20A13 12 19 NC Medicaid Medicaid and Health Choice Ambulance Services Clinical Coverage Policy No: 15 Effective Date:January 15,2020 5.1 Prior Approval Prior approval(PA) is required for non-emergency ambulance services for a Medicaid beneficiary by ground or air from North Carolina to another state, from one state to another, or from another state back to North Carolina. Medical necessity determination is based on the documentation submitted by the provider. PA must be obtained before rendering out-of-state non-emergency ambulance services. PA for ambulance service is separate from PA for a medical procedure or treatment provided out of state. Obtaining PA does not guarantee payment, ensure beneficiary eligibility on the date of service, or guarantee a post-payment review to verify that the service was appropriate and medically necessary will not be conducted. A beneficiary must be eligible for Medicaid coverage on the date the procedure is performed or the service rendered. In accordance with l0A NCAC 22J.0106 (d),the provider cannot bill beneficiaries when he fails to follow program regulations or when the claim denies on the basis of a lack of medical necessity. A provider requesting PA for state-to-state ambulance transport shall submit both the State-to-State Ambulance Transportation Addendum(Form 372-118A) and the Medicaid Prior Approval Form(Form 372-118)to NC Medicaid's designee. The request may be made by the transferring facility or the receiving facility. Forms are available at https://medicaid.ncdhhs.gov/. NCHC does not cover non-emergency medical transportation. Services must be provided in compliance with all applicable rules,regulations,laws, and current standards of practice. When requesting authorization for payment of services,the provider shall submit the beneficiary's face sheet and any other relevant information that demonstrates the beneficiary had an emergency medical condition as defined in 42 C.F.R. 489.24(c)(3). PA is not required for in-state emergency ambulance services, ground or air,for Medicaid or NCHC beneficiaries. 5.2 Prior Approval Requirements 5.2.1 General The provider(s) shall submit to the Department of Health and Human Services (DHHS)Utilization Review Contractor the following: a. the prior approval request; and b. all health records and any other records that support the beneficiary has met the specific criteria in Subsection 3.2 of this policy. 5.2.2 Specific a. Each trip requires a separate PA process and PA number b. For non-emergency medically necessary ambulance transport,PA shall be obtained before service is rendered for a Medicaid beneficiary. c. The PA is active for 30 calendar days. 20A13 13 20 NC Medicaid Medicaid and Health Choice Ambulance Services Clinical Coverage Policy No: 15 Effective Date:January 15,2020 5.3 Limitations or Requirements The provider shall bill only one ambulance procedure code for the same date of service, the same hour or time of pick-up, and the same or a different provider. The provider shall not bill a round-trip ambulance transport and a one-way-trip ambulance transport on the same date of service. If this situation occurs,the provider shall submit an adjustment request with documentation that substantiates a round trip and an additional one-way trip on the same date of service. 6.0 Provider(s) Eligible to Bill for the Procedure, Product, or Service To be eligible to bill for procedures,products, and services related to this policy,the provider(s) shall: a. meet Medicaid or NCHC qualifications for participation; b. have a current and signed Department of Health and Human Services(DHHS) Provider Administrative Participation Agreement; and c. bill only for procedures,products, and services that are within the scope of their clinical practice, as defined by the appropriate licensing entity. 6.1 Provider Qualifications and Occupational Licensing Entity Regulations None Apply. 6.2 Provider Certifications None Apply. 6.3 Licensure and Vehicles Ambulance providers shall comply with licensure and credentialing requirements of the State Office of Emergency Medical Services(OEMS)in the Division of Health Service Regulation(DHSR)and G.S. 131E-155.1. The beneficiary shall be transported in an appropriately equipped vehicle that has been inspected and issued a permit by the State OEMS and the ambulance provider shall comply with G.S. 131E-156 and 131E-157. Staffing shall be in accordance with G.S. 151E-158 and l0A NCAC 13P and appropriate for the level of care provided to the Medicaid or NCHC beneficiary. The OEMS Website is located at https://www.ncdhhs.gov/divisions/dhsr. 6.4 In-State Ambulance Service Requirements In-state ambulance service providers shall meet each of the following requirements: a. Have a valid license from the State GEMS; b. Hold a current permit issued by OEMS on the vehicle(s)used for transport; c. Participate as an ambulance provider in the Medicare program; and d. Staff the ambulance in accordance with State and local laws,including staff credentialing in accordance with OEMS. 6.5 Out-of-State Ambulance Service Requirements Out-of-state ambulance service providers shall meet all of the following requirements: a. A valid license as an ambulance provider under the laws of the state in which the provider operates; b. An enrolled Medicaid ambulance provider in the state in which the provider operates; 20A13 14 21 NC Medicaid Medicaid and Health Choice Ambulance Services Clinical Coverage Policy No: 15 Effective Date:January 15,2020 c. An enrolled Medicare ambulance provider; and d. Enrolled with an N.C. Medicaid provider number. 7.0 Additional Requirements Note:Refer to Subsection 2.2.1 regarding EPSDT Exception to Policy Limitations for a Medicaid Beneficiary under 21 Years of Age. 7.1 Compliance Provider(s) shall comply with the following in effect at the time the service is rendered: a. All applicable agreements, federal, state and local laws and regulations including the Health Insurance Portability and Accountability Act(HIPAA) and record retention requirements; and b. All NC Medicaid's clinical(medical)coverage policies,guidelines,policies,provider manuals, implementation updates, and bulletins published by the Centers for Medicare and Medicaid Services(CMS),DHHS,its divisions or its fiscal agent. 7.2 Call Reports The ambulance provider shall maintain all call reports,PA forms, documentation to support the miles billed, and any other records prepared or received in regard to the service rendered to Medicaid and NCHC beneficiaries and claimed for reimbursement. The provider shall retain the records for a minimum of six years from the date of service, unless a longer retention period is required, and shall be made available to NC Medicaid or its NC Medicaid's designee upon request. Submission of call reports is not required when filing ambulance claims. A call report shall be legible, complete, and accurate and: a. Include a complete description of the beneficiary at the scene and in transit: 1. Detail the condition necessitating the ambulance service; 2. Include a physical description of the beneficiary's position,location, and status during the initial encounter(for example, lying on the floor or sitting in a wheelchair); 3. Include data on how,when, and where the beneficiary was found; all vital signs; level of consciousness; and other relevant information; 4. Document all treatments rendered and the beneficiary's response to treatment; 5. Use sufficient detail to justify that the beneficiary's health and safety would be endangered if transported other than by stretcher; and 6. Use sufficient detail to support the medical necessity of the transport,the condition codes billed, and the level of care provided.If the ambulance service does not meet medical necessity and coverage criteria,the provider shall document this information on the call report to ensure a complete and accurate record of the beneficiary's condition. b. Include the time in the range of 00-23 hours,the point of pickup,the destination, and the number of loaded miles; c. Document that the transport is to the nearest appropriate facility; and d. Document one-way or round-trip ambulance transport. 20A13 15 22 NC Medicaid Medicaid and Health Choice Ambulance Services Clinical Coverage Policy No: 15 Effective Date:January 15,2020 7.3 Physician Certification and Order for Non-Emergency Medicaid Ambulance Services The ambulance provider shall obtain the signed written order and certification with the appropriate signatures before billing for the following services: 7.3.1 Non-Emergency, Scheduled,Repetitive Ambulance Services For all non-emergency, scheduled,repetitive ambulance services,ambulance providers shall obtain from the Medicaid beneficiary's attending physician a written order certifying the medical necessity of the ambulance services. The physician's order shall be dated no earlier than 60 calendar days before the date the service is furnished. 7.3.2 Non-Emergency Ambulance Services That Are Either Unscheduled or That Are Scheduled on a Non-Repetitive Basis For a Medicaid beneficiary who is under the care of a physician,the ambulance provider shall obtain a written order certifying the medical necessity from the beneficiary's attending physician within 48 hours after the transport. If the ambulance provider cannot obtain the written order and certification with appropriate signatures within 21 calendar days following the date of service,the provider shall document the attempts to obtain the requested order and certification and may then submit the claim to NC Medicaid's designee. If the ambulance provider cannot obtain a signed physician certification statement from the beneficiary's attending physician,he shall obtain a signed certification statement from either the physician assistant(PA),nurse practitioner (NP), clinical nurse specialist(CNS),registered nurse(RN), or discharge planner who has personal knowledge of the beneficiary's condition at the time the ambulance transport is ordered, or the service is furnished. This individual shall be employed by the beneficiary's attending physician or by the hospital or facility where the beneficiary is being treated and from which the beneficiary is transported. A physician order is not required for a Medicaid beneficiary who resides at home or in a facility and is not under the direct care of a physician. The presence of the signed physician certification statement does not necessarily demonstrate that the transport was medically necessary and that it met coverage criteria. The ambulance provider shall meet all coverage criteria, including call report criteria, in order for reimbursement to be made. 20A13 16 23 NC Medicaid Medicaid and Health Choice Ambulance Services Clinical Coverage Policy No: 15 Effective Date:January 15,2020 8.0 Policy Implementation and History Original Effective Date: February 1, 2016 History: Date Section or Change subsection Revised 02/01/2016 All sections and New policy documenting current coverage and services attachment(s) 03/15/2019 Table of Contents Added, "To all beneficiaries enrolled in a Prepaid Health Plan(PHP): for questions about benefits and services available on or after November 1,2019,please contact your PHP." 03/15/2019 All Sections and Updated policy template language. Attachments 08/15/2019 Section 3.2.1.5 Added Subsection"3.2.1.5 Transport to Behavioral Health Crisis Centers" NC Medicaid shall cover transport of Medicaid beneficiaries in behavioral health crisis to behavioral health clinics or alternative appropriate care locations when the following criteria are met: a. Emergency Medical Services (EMS)providers have received appropriate education in caring for beneficiaries in behavioral health crisis; b. EMS system has at least one partnership with a receiving facility that is able to provide care appropriate for those beneficiaries; and c. EMS systems shall be required to include in its EMS system plan a report on beneficiary experiences and outcomes in accordance with rules adopted by Department of Health and Human Services(DHHS),Division of Health Service Regulation(DHSR),Division of Health Benefits (DHB), and Office of Emergency Services(OEMS) Session Law 2018-5 11HA(a) 08/15/2019 Section 3.2.3.1 (g) Added: Emergency transport to a behavioral health clinic or other appropriate location during a behavioral health crisis. Effective Date: July 1, 2019 01/15/2020 Table of Contents Updated policy template language, "To all beneficiaries enrolled in a Prepaid Health Plan(PHP): for questions about benefits and services available on or after implementation,please contact your PHP." 01/15/2020 Attachment A Added, "Unless directed otherwise, Institutional Claims must be billed according to the National Uniform Billing Guidelines. All claims must comply with National Coding Guidelines". 20A13 17 24 NC Medicaid Medicaid and Health Choice Ambulance Services Clinical Coverage Policy No: 15 Effective Date:January 15,2020 Attachment A: Claims-Related Information Provider(s) shall comply with the,NCTracks Provider Claims and Billing Assistance Guide,Medicaid bulletins,fee schedules,NC Medicaid's clinical coverage policies and any other relevant documents for specific coverage and reimbursement for Medicaid and NCHC: A. Claim Type Institution-based ambulance providers bill institutional(UB-04/8371) Independent/private ambulance providers bill professional(CMS-1500/837P) Unless directed otherwise,Institutional Claims must be billed according to the National Uniform Billing Guidelines.All claims must comply with National Coding Guidelines B. International Classification of Diseases and Related Health Problems, Tenth Revisions, Clinical Modification (ICD-10-CM) and Procedural Coding System (PCS) Provider(s) shall report the ICD-IO-CM and Procedural Coding System(PCS)to the highest level of specificity that supports medical necessity. Provider(s) shall use the current ICD-10 edition and any subsequent editions in effect at the time of service.Provider(s) shall refer to the applicable edition for code description, as it is no longer documented in the policy. C. Code(s) Provider(s) shall report the most specific billing code that accurately and completely describes the procedure,product or service provided. Provider(s) shall use the Current Procedural Terminology (CPT),Health Care Procedure Coding System(HCPCS), and UB-04 Data Specifications Manual (for a complete listing of valid revenue codes) and any subsequent editions in effect at the time of service. Provider(s) shall refer to the applicable edition for the code description,as it is no longer documented in the policy. If no such specific CPT or HCPCS code exists,then the provider(s) shall report the procedure, product or service using the appropriate unlisted procedure or service code. HCPCS Codes Institutional and professional providers use the following HCPCS code(s)to identify the service being rendered. HCPCS Code(s) A0425 A0430 A0426 * A0431 A0427 A0433 A0428 * A0435 A0429 A0436 T2003* * This code is not covered under the NCHC program.NCHC does not cover non-emergency ambulance transportation. 20A13 18 25 NC Medicaid Medicaid and Health Choice Ambulance Services Clinical Coverage Policy No: 15 Effective Date:January 15,2020 Revenue Codes Institutional providers must report revenue code(RC) 540 and one of the HCPCS codes listed above for each ambulance trip provided. Institutional providers must report RC 540 and a mileage code,when applicable, on a separate detail line. Revenue Code RC540 Condition Codes Institutional providers must report one of the condition codes listed below: Condition Code AK Air Ambulance Required AL Specialized Treatment/Bed Unavailable(transported to alternate facility) AM Non-Emergency Medically Necessary Stretcher Transport Required Medical Conditions List Refer to the Medicare Claims Processing Manual, Chapter 15-Ambulance, Section 40-Medical Conditions List and Instructions located at http://www.cros. og v/Regulations-and-Guidance/Guidance/Manuals/Downloads/clml04c15.pdf Unlisted Procedure or Service CPT: The provider(s) shall refer to and comply with the Instructions for Use of the CPT Codebook,Unlisted Procedure or Service, and Special Report as documented in the current CPT in effect at the time of service. HCPCS: The provider(s) shall refer to and comply with the Instructions For Use of HCPCS National Level 1I codes,Unlisted Procedure or Service and Special Report as documented in the current HCPCS edition in effect at the time of service. A Modifiers Provider(s) shall follow applicable modifier guidelines. Providers must report an origin and destination modifier for each ambulance trip provided. Origin and destination modifiers used for ambulance services are created by combining two alpha characters.Each alpha character,with the exception of"x,"represents an origin code or a destination code. The pair of alpha codes creates one modifier. The first position alpha code equals origin;the second position alpha code equals destination. The modifier description is listed in the Health Care Procedure Coding System(HCPCS). Provider(s) shall refer to the applicable edition for the code description as it is no longer documented in the policy. Alpha Codes D I R E J S G N X H P 20A13 19 26 NC Medicaid Medicaid and Health Choice Ambulance Services Clinical Coverage Policy No: 15 Effective Date:January 15,2020 Providers must report QL modifier if the time of death pronouncement is made after dispatch but before the beneficiary is loaded onboard the ambulance. E. Billing Units Provider(s) shall report the appropriate code(s)used which determines the billing unit(s). The time of pick-up, in the range of 00-23 hours,is required on the claim form. When multiple units respond to a call for services,the provider that transports the beneficiary is the only provider that may bill for the service. If both ground and air medical ambulances are involved,then each submits its own claim and each claim is processed and reimbursed independently of the other. F. Place of Service Ambulance G. Co-payments For Medicaid refer to Medicaid State Plan: https:Hmedicaid.ncdhhs.gov/get-involved/nc-health-choice-state-plan For NCHC refer to NCHC State Plan: https:Hmedicai d.ncdhhs.gov/get-involved/nc-health-choice-state-plan H. Reimbursement Provider(s) shall bill their usual and customary charges. For a schedule of rates,refer to: https://medicaid.ncdhhs.gov/ Reimbursement is based on the level of service rendered,not the type of vehicle. The level of service is determined by medical necessity and qualifying criteria. Reimbursement includes both the transport of the Medicaid or NCHC beneficiary to the nearest appropriate facility and all supplies (disposable and nondisposable,including oxygen)associated with such transport. Reimbursement is allowed for a round trip only if the ambulance remained in the vicinity of the destination, did not return to base, and did not respond to other calls for transport. Otherwise,the provider should bill for two one-way trips. Medicaid and NCHC providers shall not bill for additional reimbursement for waiting time on round trips. Waiting time is included in the round- trip reimbursement.Medicaid and NCHC providers shall not bill a beneficiary for waiting time on round trips. If a beneficiary is transported and returned to the point of pick-up or other delivery point by a different provider on the same date of service, each provider is allowed a one-way trip. The level of reimbursement is determined by medical necessity and qualifying criteria. Ambulance transport of a Medicaid or NCHC hospice beneficiary for any service related to the terminal illness is the responsibility of the hospice provider. The ambulance provider shall contact the hospice provider prior to transport to arrange for payment. The ambulance provider shall not bill Medicaid or NCHC. 20A13 20 i 27 '1 EMS1 MC EMS MANAGEMENT&CONSULTANTS North Carolina Medicaid Reform Fact Sheet Updated 08/11/2020 EMS I MC has prepared this fact sheet to assist NC EMS providers to navigate through the changes to the North Carolina Medicaid program now launching on July 1, 2021. The NC Association of EMS Administrators (NCAEMSA) and EMS I MC are working closely with the NC Department of Health and Human Resources (DHHS)to ensure that we have a seat at the table as these important decisions are made. There are many aspects of the NC Medicaid Reform that will impact EMS providers in NC. The purpose of this fact sheet is to explain the most recent updates to Medicaid Managed Care. Medicaid Managed Care On February 4, 2019, NC Medicaid announced the contract awards to the managed care plans that will administer the Medicaid program. Using a competitive procurement process, NC Medicaid has awarded four statewide Prepaid Health Plans (PHP) and one regional, provider-led entity,to the following agencies: • AmeriHealth Caritas North Carolina, Inc. • WellCare of North Carolina, Inc. • BCBS of North Carolina • Carolina Complete Health (Regions 3 and 5) • UnitedHealthcare of North Carolina, Inc. Timeline MANAGED CARE & OPEN AUTO TRIBAL OPTION ENROLLMENT ENROLLMENT LAUNCH 3115121 5114121 7/1121 OPEN ENROLLMENT TRANSITION OF CARE NC EMS Providers will be expected to contract with the PHPs in order to receive payment for services provided to these Medicaid recipients. Claims will be filed to the PHP for eligible Medicaid recipients rather than directly to NC Medicaid. Infocrossing, LLC has been named the Provider Data Contractor, whose responsibilities will include credentialing of Medicaid-enrolled providers and sharing the information with the PHPs. The goal of the Provider Data Contractor will ensure a consistent process of enrollment. Under the managed care program,the Department will mandate that the PHP maintain a certain level of payment by establishing a rate floor, or minimum payment of 100%of the Medicaid fee- for-service rates. EMS MC I I i 28 '1 EMSIMC EMS MANAGEMENT&CONSULTANTS Providers will be permitted to mutually agree to a different rate or alternative payment arrangement through the provider contracts. The Department will also set guidelines for out-of-network provider payments. PHP will be required to cover the same services as Medicaid fee-for-service and may agree to pay for additional services if proven to be beneficial to the recipient's care plan. Challenges & Risks COVID-19 pandemic introduces complexity and uncertainty in project planning Tailored Plan Request for Application (RFA) and operational transition in preparation for July 2022 launch DHHS is working with the Eastern Band of Cherokee Indians to develop a PCCM "Tribal Option"to go live in Region 1 EMS MC's Role EMS MC will continue to monitor the implementation of the North Carolina Medicaid Reform and will provide ongoing updates to our EMS Providers. We will be happy to assist you in contract negotiation now that the MCOs have been selected. Our Payor Relations Team will be completing the provider enrollment process on your behalf and will be reaching out to you to obtain any necessary information. EMS I MC has held preliminary meetings with a few of the health plans in anticipation of this award. We will continue to meet with the plans to advocate for increased reimbursement on behalf of our clients. We are excited about the possibilities of increased coverage for services such as Mobile Integrated Healthcare (MIH) which have been very appealing to the mission of the Department and the PHPs. EMS I MC will be fully prepared to submit claims to all Managed Care Organizations can your behalf upon implementatioi If you have any further questions, please feel free contact your Strategic Account Manager. REGION 2 REGION 4 REGION 6 uiEDXwY 7@� REGION1 RSXE RDRRf 519XF5 RPCNINGXAM nAIAUDp WAKES YADKIX � AIERr FDA3YIX GUIIFDRD f- D MVUL IEXAIID[ UWE l WWII rAXCEY 4 IREARL DAVIDSON �. BURM BVNCOMBE MCDOWEII Cp1AW&l RRRWN 111 wAYWWP SWAIN IINCOw Nuh-WORD cABRRRUR FiRAMAM NENOERSOx IACXSOH KIK CLEYEIAND MTON SIANIY SYIYAIYV. MECKIFNAUR CHEROKEE IR' r CAY UNION WON REGION 3 r! REGION 5 EMSIMC H I EMS MANAGEMENT 81 CONSULTANTS