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Questions about Ambulance Rates or Medicare Denials
Medicare is health insurance for people age 65 or older, or those under age 65 with certain disabilities. Ambulance services are covered under Medicare Part B (Medical Insurance).
Medicare will cover medically necessary ambulance transportation to the nearest appropriate facility. Generally, only local transportation by ambulance is covered, and therefore, only mileage to the nearest appropriate facility equipped to treat the patient is covered.
Medicare beneficiaries entitled to Medicare Part A (Hospital Insurance) have the option of electing hospice benefits in lieu of standard Medicare coverage for treatment and management of their terminal condition. When hospice coverage is elected, the beneficiary waives all rights to Medicare Part B payments for services that are related to the treatment and management of the terminal illness during any period the beneficiary's hospice benefit election is in force, except for professional services of an "attending physician."
You have the right to appeal any decision about your Medicare services. This is true whether you are in Original Medicare or a Medicare managed care plan. If Medicare does not pay for an item or service you have been given, you can appeal. Your appeal rights are on the back of the Explanation of Medicare Benefits or Medicare Summary Notice that is mailed to you. The notice will also tell you why your bill was not paid and what appeal steps you can take. The phone number to contact Medicare directly is 1-800-MEDICARE or 1-800-633-4227. The Medicare and You handbook along with other valuable Medicare information for beneficiaries can be accessed at: http://www.medicare.gov
- Why did Medicare deny the ambulance claim? Please read, Medicare Pulls Back on Ambulance Services
- Official Government booklet: Medicare Coverage of Ambulance Services
In Missouri, you can also contact CLAIM for assistance with your Medicare benefits. CLAIM is Missouri's State Health Insurance Assistance Program. CLAIM is nonprofit providing free, unbiased information about Medicare to Missourians. Their goal is to provide local counselors to help the Medicare beneficiary get the most from your Medicare benefits. The phone number to contact CLAIM is 1-800-390-3330. Their website address is: http://www.missouriclaim.org
Insurance companies have timely filing limits, which often vary from 30 days to 1 year. Therefore, timely billing is extremely important. TCAD will not be responsible for claims not filed within the timely filing period. The patient is responsible to follow up for payment with their insurance. If your insurance fails to pay your claim within the 45 day grace period, payment will become patient responsibility.
Insurance coverage varies widely from policy to policy. Please contact your insurance company if you have any questions about your policy or coverage. If your policy does not provide 100% coverage for ambulance transportation, you may be required to pay a deductible, co-payment or co-insurance. Payment of all deductibles, co-payments and co-insurance is due upon receipt of your invoice.
Medicaid is a State program intended to assist indigent citizens. Medicaid programs are administered by each State. Missouri Statute 208.152 authorizes MO HealthNet coverage of emergency ambulance services. Ambulance services are covered if they are emergency services and transportation is made to the nearest appropriate hospital.
Emergency services are services required when there is a sudden or unforeseen situation or occurrence or a sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that the absence of immediate medical attention could reasonably be expected to result in:
- Placing the patient's health in serious jeopardy; or
- Serious impairment to bodily functions; or
- Serious dysfunction of any bodily organ or part.
The phone number for Medicaid participants to contact MO HealthNet is 1-800-392-2161.
The MO HealthNet Participant Handbook can be accessed at: https://dss.mo.gov/mhd/participants/pdf/hndbk_ffs.pdf
Other valuable information can be obtained on their website at: http://www.dss.mo.gov/mhd/participants/index.htm
When a MO HealthNet participant elects hospice services, the hospice provides or arranges for all care, supplies, equipment and medicines related to the terminal illness. MO HealthNet pays the hospice who then pays the provider. Ambulance services related to the terminal illness must be authorized or requested by the hospice provider and are reimbursed by the hospice provider.
Non-emergency medical transportation (NEMT) is available to eligible MO HealthNet participants who do not have access to free appropriate transportation to and from scheduled MO HealthNet covered services. NEMT services are arranged through contractor selected by MO HealthNet. To see if you are eligible for NEMT, call 1-866-269-5927. NEMT services are available 24 hours per day, 7 days per week, when medically necessary. To provide adequate time for NEMT services to be arranged, a participant should call at least three (3) days in advance.