1. A. This document provides the basis for identification of procedures to be reimbursed to transportation vendors. The coding source is the health care financing administration common procedure coding system (HCPCS). No other coding methodology will be accepted by the carrier/self-insured employer. Please do not bill using any of the modifiers. Modifiers will not affect payment and may cause your bill to be unnecessarily delayed.

2. B. This fee schedule provides the basis for reimbursement of medical transportation. Reimbursement is limited to the least of:

   1. 1. the provider's usual and customary charge;
   2. 2. a reimbursement amount previously negotiated by the provider and the carrier/self-insured employer; or

   3. 3. the maximum allowable reimbursement as determined by the following schedule.

      State of Louisiana Office of Workers' Compensation Schedule of Maximum Allowances for Medical Transportation
      HCPCS	Description	Maximum Allowable
      A0140	Nonemergency Transportation and Air Travel (Private or Commercial), Intra or Interstate	B.R.
      A0999	Unlisted Ambulance Service	B.R.
      A0380	Emergency Ambulance Service, BLS per Mile, One Way	$6
      A0390	Emergency Ambulance Service, (ALS) Per Mile, One Way	$7
      A0420	Ambulance Service, Waiting Time, One Half (1/2) Hour Increments, Rate per Unit (See Table Below)	$42
      A0422	Ambulance Service, Oxygen, Administration and Supplies, Life Sustaining Situation	B.R.
      A0427	Emergency Ambulance Service, Advanced Life Support (ALS) Base Rate, All Inclusive Services, One Way	$375
      A0428	Nonemergency Transportation, Ambulance, Base Rate, One Way	$169
      A0429	Emergency Ambulance Service, BLS Rate One Way	$258
      A0430	Ambulance Service, Conventional Air Service One Way	B.R.
      A0431	Ambulance Service, Air, Helicopter, v	B.R.

Authority Note

AUTHORITY NOTE: Promulgated in accordance with R.S. 23:1034.2.

Historical Note

HISTORICAL NOTE: Promulgated by the Department of Labor, Office of Workers' Compensation, LR 19:54 (January 1993), repromulgated LR 19:212 (February 1993), amended LR 20:1299 (November 1994), amended by the Workforce Commission, Office of Workers’ Compensation, LR 39:1841 (July 2013).