Medicare medical necessity for ambulance transport form

{"DID":"crit13242b","Sites":"JJA^JJB^JMA^JMB^JMHHH","Start Date":"10-06-2022 16:01","End Date":"10-10-2022 13:00","Content":"The Palmetto GBA Jurisdictions J and M Provider Contact Center (PCC) will be closed from 8 a.m. to 12 p.m. ET on Columbus Day, Monday, October 10, 2022, for staff training.","URL":"","Target":null,"Color":"blue","Mode":"Standard\n","Priority":"no"}, {"DID":"crit1bace2","Sites":"JJA^JJB^JMA^JMB^JMHHH^Railroad Medicare","Start Date":"05-04-2022 08:25","End Date":"05-04-2022 08:25","Content":"Users are unable to view remits in the eServices portal. We are working to resolve the issue and will remove this message when functionality is restored.","URL":"","Target":"_self","Color":"red","Mode":"Standard\n"}, {"DID":"crit3d3a1d","Sites":"JJA^JJB^JMA^JMB^JMHHH","Start Date":"11-10-2022 08:23","End Date":"11-11-2022 13:00","Content":"The Palmetto GBA Jurisdictions J and M Provider Contact Center (PCC) will be closed from 8 a.m. to 12 p.m. ET on Veteran���s Day, Friday, November 11, 2022, for staff training.","URL":"","Target":null,"Color":"blue","Mode":"Standard\n","Priority":"no"}, {"DID":"crit3eaacc","Sites":"JJA^JJB^JMA^JMB^JMHHH","Start Date":"09-14-2022 13:34","End Date":"09-16-2022 13:00","Content":"The Palmetto GBA Provider Contact Center (PCC) will be closed 8 a.m. to 12 p.m. ET on Friday, September 16, 2022, for staff training.","URL":"","Target":null,"Color":"blue","Mode":"Standard\n","Priority":"no"}, {"DID":"crit4d544a","Sites":"JJA^JJB^JMA^JMB^JMHHH","Start Date":"09-27-2022 12:31","End Date":"09-30-2022 13:00","Content":"The Palmetto GBA Provider Contact Center (PCC) will be closed 8 a.m. to 12 p.m. ET on Friday, September 30, 2022, for staff training.","URL":"","Target":"_self","Color":"blue","Mode":"Standard\n","Priority":"no"}, {"DID":"critce435c","Sites":"JJA^JJB^JMA^JMB^JMHHH","Start Date":"10-20-2022 13:41","End Date":"10-21-2022 13:00","Content":"The Palmetto GBA Jurisdictions J and M Provider Contact Center (PCC) will be closed from 8 a.m. to 12 p.m. ET on Friday, October 21, 2022, for staff training.","URL":"","Target":null,"Color":"blue","Mode":"Standard\n","Priority":"no"}, {"DID":"critd42c51","Sites":"JJA^JJB^JMA^JMB^JMHHH^Railroad Medicare","Start Date":"11-01-2022 15:33","End Date":"11-05-2022 12:00","Content":"eServices will be unavailable on Saturday, November 5, 2022, starting at 7 a.m. for planned maintenance. We expect eServices to be available late morning. We apologize for any inconvenience.","URL":"","Target":"_self","Color":"yellow","Mode":"Standard\n","Priority":"no"}

Medicare Part B (Medical Insurance)

covers ground ambulance transportation when traveling in any other vehicle could endanger your health, and you need medically necessary services from a:

• Hospital
• Critical access hospital, or
• Skilled nursing facility

Medicare may pay for emergency ambulance transportation in an airplane or helicopter if you need immediate and rapid transport that ground transportation can’t provide.

In some cases, Medicare may pay for limited, medically necessary, non-emergency ambulance transportation if you have a written order from your doctor stating that the transportation is medically necessary. For example, someone with End-Stage Renal Disease may need medically necessary ambulance transport to a kidney dialysis facility.

Your costs in Original Medicare

After you meet the Part B deductible , you pay 20% of the Medicare-Approved Amount .

Note:

Your doctor or other health care provider may recommend you get services more often than Medicare covers. Or, they may recommend services that Medicare doesn’t cover. If this happens, you may have to pay some or all of the costs. Ask questions so you understand why your doctor is recommending certain services and if, or how much, Medicare will pay for them.

Things to know

Medicare will only cover ambulance services to the nearest appropriate medical facility that’s able to give you the care you need.

The ambulance company must give you an "

Advance Beneficiary Notice Of Noncoverage (Abn)

" when both of these apply:

• You got ambulance services in a non-emergency situation.
• The ambulance company believes that Medicare may not pay for your specific ambulance service.

Note:

You may now be affected by a Medicare demonstration program if:

• You get scheduled, non-emergency ambulance transportation for 3 or more round trips in a 10-day period or at least once a week for 3 weeks or more
• You get this transportation from any ambulance company nationwide

Under this demonstration, your ambulance company may send a request for prior authorization to Medicare before your fourth round trip in a 30-day period. They'll do this so you and the company will know earlier in the process if Medicare is likely to cover your services. 

If your prior authorization request isn't approved and you continue getting these services, Medicare will deny the claim and the ambulance company may bill you for all charges. Either you or your ambulance company may request prior authorization for these scheduled, non-emergency ambulance services. If your prior authorization request isn’t approved and you continue getting these services, Medicare will deny the claim and the ambulance company may bill you for all charges. For more information, call us at 1-800-MEDICARE (1-800-633-4227). TTY: 1-877-486-2048.