Effective January 1, 2020, Independence will cover
emergency ambulance response and treatment without transport in accordance with
the Commonwealth of Pennsylvania's mandate (Act 103 of 2018) for members
enrolled in Pennsylvania products that are subject to the mandate when
all the following medical necessity criteria are met:
- the services provided are medically necessary to stabilize the
individual’s medical condition;
- the responding emergency medical services (EMS) ambulance is
Pennsylvania-licensed and rendering EMS services in the Commonwealth of
Pennsylvania;
- the responding EMS ambulance, in accordance with state regulations, is a
specially designed and equipped vehicle used to transport the sick or
injured;
- the responding EMS ambulance, in accordance with state regulations, is
staffed by state certified or qualified staff who can provide basic life
support or advanced life support services, as appropriate, at the treating
location during the time of the emergency;
- the responding EMS staff provides on scene emergency evaluation and, if
necessary, treatment to stabilize the individual's medical condition, and it is
subsequently determined that transportation to an acute care hospital or other
emergency care facility for additional care is not required, or the individual
declines transportation.
HCPCS code A0998 will be considered eligible for reimbursement in a
situation where:
- EMS staff respond to an emergency call and provide on scene emergency
evaluation. AND
- If necessary, provide treatment to stabilize an individual’s
condition but does not provide transportation – either because the
medical issue has resolved or the individual declined transportation.
Updated policy
Medical Policy #12.04.02i: Ground Ambulance Services (Emergency and
Nonemergency) (Independence) was updated and posted as a Notification on
October 3, 2019, and will go into effect January 1, 2020.
To view the Notification for this policy, visit our Medical Policy
Portal.