[
As of April 19, 2015, claims from providers of emergency and non-emergency
air ambulance services provided
within the U.S., U.S. Virgin Islands, and Puerto Rico are to be filed with the
local Plan in whose service area the
point of pick-up occurred, per a new requirement from the Blue Cross and Blue
Shield Association, an association of
independent Blue Cross and Blue Shield plans. This change applies to the
following air ambulance service codes:
A0430, A0431, A0435, A0436, S9960, S9961, and T2007.
Claims without a point of pick-up ZIP code, or claims with multiple ZIP
codes, will be rejected.
Upon receiving the claim, the Host Plan must validate the point of pick-up
ZIP code for air ambulance service on
claims with dates of service on or after April 19, 2015. Validation is based on
the following guidelines from the Centers for Medicare & Medicaid Services
(CMS) for air ambulance claims:
- CMS-1500 (2/12) claim form or 837P. In item 23 of the CMS-1500 claim
form, or the equivalent field of the 837 professional transaction (loop 2420G),
billers shall code the five-digit ZIP code of the point of pick-up. If the ZIP
code is not in the Plan's service area, the claim will be rejected.
- UB-04 claim form or 837I. When the UB-04 claim form is used for air
ambulance service (excluding claims
submitted with a facility's negotiated arrangement with an air ambulance
provider), billers shall populate Form
Locators 39-41 with Value Code "A0" and the five-digit ZIP code of the point of
pick-up (corresponding 837I field:
Loop 2300, HI01-1 = BE, HI01-2 = A0, HI01-5 = Pick-up ZIP code). The Form
Locator must be populated with the
approved code and value specified by the National Uniform Billing Committee in
the UB-04 Data Specifications
Manual.
- Format. The format for a ZIP code is five digits. If a nine-digit
ZIP code is submitted, the last four digits will be ignored. If the data
submitted in the required field does not match that form, the claim will be
rejected.
If you have any questions about this requirement, please contact Customer
Service at
1-800-ASK-BLUE.
]