Wyo. Code R. 048-0037-15
Medicaid
Chapter 15: Ambulance Services
Effective Date: 02/08/2017 to 05/14/2018
Rule Type: Superceded Rules & Regulations
Reference Number: 048.0037.15.02082017
This Chapter is promulgated by the Department of Health pursuant to the Medical Assistance and Services Act at W.S. § 42-4-101 through W.S. § 42-4-306 and the Wyoming Administrative Procedures Act at W.S. § 16-3-101 through W.S. § 16-3-115.
This rule establishes the scope of ambulance services covered by Medicaid and the methods and standards for reimbursing providers of such services.
(a) For any code, standard, rule or regulation incorporated by reference in these rules:
(i) The Department of Health has determined that incorporation of the full text in these rules would be cumbersome or inefficient given the length or nature of the rules.
(ii) The incorporation by reference does not include any later amendments or editions of the incorporated matter beyond the applicable date identified in subsection (b) of this section.
(iii) The incorporated code, standard, rule or regulation is maintained at the Department of Health and is available for public inspection and copying at cost at the same location.
(b) Each rule incorporated by reference and can be found at http://soswy.state.wy.us/rules/ and is further identified as follows:
(i) Referenced in Section 5 is Wyoming Medicaid Rule, Chapter 1 – Definitions, adopted by the Department of Health and effective on November 7, 2011.
(ii) Referenced in Section 6 is Wyoming Medicaid Rule, Chapter 3 – Provider Participation, adopted by the Department of Health and effective on December 16, 1998.
(iii) Referenced in Section 7 is Wyoming Office of Emergency Medical
Services and Trauma Rules as effective January 1, 2017.
(a) The Department may issue manuals, bulletins, or both to interpret the provisions of this rule. Such manuals and bulletins shall be consistent with and reflect the administrative interpretations contained in this rule.
Section 5. Definitions. Except as otherwise specified in Chapter 1, the terminology used in this Chapter is the standard terminology and has the standard meaning used in healthcare, Medicaid and Medicare.
(a) Eligible providers. An individual or entity that:
(i) Holds a current ambulance business license pursuant to the Wyoming Emergency Medical Services Act of 1977, found at W.S. § 33-36-101 through W.S. § 33-36-115, or, if the provider is located outside Wyoming, is licensed under applicable provisions of that state’s law; and
(ii) Meets all Medicare certification requirements.
(b) Compliance with Wyoming Medicaid Rule, Chapter 3. A person or entity that wishes to receive Medicaid reimbursement for covered services furnished to a recipient must meet the provider participation requirements of Wyoming Medicaid Rule, Chapter 3.
(c) Right of inspection. The Office of Emergency Medical Services and Trauma may inspect any ambulance at any time or place to determine whether the ambulance is being operated safely and in compliance with these and other applicable laws. An ambulance which does not pass an inspection shall not receive Medicaid reimbursement for furnishing covered services to a client until the ambulance has passed a re-inspection by the Office of Emergency Medical Services and Trauma.
The terms in this section shall be interpreted to follow the definitions and classifications established by the Office of Emergency Medical Services and Trauma Rules.
(a) Emergency ground ambulance transportation.
(i) Ground ambulance is any motor vehicle maintained, operated or advertised for the medical care and transportation of patients upon any street, highway or public way, or any motor vehicle owned and operated on a regular basis by the State of Wyoming or any agency, municipality, city, town, county or political subdivision of Wyoming for medical care and transportation of patients upon any street, highway or public way.
(b) Basic Life Support (BLS) or Advanced Life Support (ALS).
(i) Basic Life Support (BLS) is treatment rendered by personnel licensed at the Emergency Medical Responder (EMR) or basic Emergency Medical Technician (EMT) level, including procedures such as bandaging, splinting, basic first aid, and performing CPR.
(ii) Advanced life support (ALS) is treatment rendered by personnel licensed at the Emergency Medical Responder (EMR) or Emergency Medical Technician (EMT) level, with additional training certifying them to perform additional procedures such as cardiac monitoring and defibrillation, advanced airway management, intravenous therapy, and the administration of medications.
(iii) Advanced Life Support Level 1- Emergency (ALS1- emergency) is transportation by ground ambulance with provision of medically necessary supplies, oxygen, and at least one ALS intervention. The ambulance and its crew must meet licensure standards for ALS care.
(A) An ALS intervention refers to the provision of care outside the scope of an EMT and must be medically necessary (e.g., medically necessary ECG monitoring, drug administration, etc.)
(iv) Advanced Life Support Level 2 (ALS2) is covered for the provision of medically necessary supplies and services including (1) at least three separate administrations of one or more medications by intravenous push/bolus or by continuous infusion (excluding crystalloid fluids); or (2) ground ambulance transport, medically necessary supplies and services, and the provision of at least one of the ALS2 procedures listed below:
(v) ALS or BLS ground ambulance is a covered service if:
(A) The use of any other method of transportation could endanger the health of the client;
(B) The client is transported to the nearest appropriate facility, which is a facility that offers services sufficient to meet the medical needs of the client; and (C) The client is admitted to the receiving facility as an inpatient or an outpatient.
(D) Reimbursement for ALS services is available only if such services are medically necessary and actually rendered to the client.
(1) An ALS assessment is an assessment performed by an ALS crew as part of an emergency response that was necessary because the patient's reported condition at the time of dispatch was such that only an ALS crew was qualified to perform the assessment. An ALS assessment does not necessarily result in a determination that the patient requires an ALS level of service.
(c) Non-emergency transportation. Non-emergency transportation provided in a ground ambulance is a covered service if any other mode of transportation would endanger the health or life of the individual and the individual meets at least one of the criteria listed below. The individual is:
(d) Advanced Life Support Level 1- Non-Emergent (ALS1- non-emergent) in non-emergent circumstances.
(i) Follows the same criteria as ALS 1 – emergency set out above in Section 7(b)(iii).
(e) Air ambulance services (i) Fixed-wing aircraft or helicopter licensed to provide ambulance services. (ii) Transportation provided in an air ambulance is covered if: (A) The client has a life-threatening condition and the use of any other method of transportation, including ground ambulance, could endanger the health of the client; or (B) The client's location is inaccessible by ground ambulance. (C) Air transport is more cost effective than any other alternative. (f) Community Emergency Medical Services as described and certified by the Office of Emergency Medical Services and Trauma to include: (i) Community Emergency Medical Services – Technical (CEMS-T) (ii) Community Emergency Medical Services – Clinical (CEMS-C)
Section 8. Excluded Services. The following are not covered services:
(a) Transportation to receive services that are not covered services; (b) No-load trips and unloaded mileage (when no patient is aboard the ambulance), including transportation of life-support equipment in response to an emergency call; (c) Transportation of a client who is pronounced dead before an ambulance is called or after the ambulance is called but before transport; (d) Transportation of a family member or friend to visit a client or consult with the client's physician or other provider of medical services; (e) Transportation to pick up pharmaceuticals; (f) A client's return home when ambulance transportation is not medically necessary, including a client's return back to a nursing facility; (g) Transportation of a resident of a nursing facility to receive services that are available at the nursing facility; (h) Air ambulance services to transport a client from a hospital capable of treating the client to another hospital because the client or family prefers a specific hospital or practitioner; (i) Transportation of a client in response to detention ordered by a court or law enforcement agency;
(j) Transportation based on a physician's standing orders; (k) Stand-by time; (l) Special attendants; (m) Specialty Care Transport (SCT); (o) Paramedic Intercept (PI);
(p) When a client can be transported by a mode other than ambulance without endangering the client's health, regardless of whether other transportation is available.
(a) Services that require prior authorization. (i) The Department may designate ambulance services that require prior authorization. (ii) In designating services that require prior authorization, the Department shall consider the: (A) Cost of the service; (B) Potential for over-utilization of the service; and (C) Availability of lower cost alternatives. (b) The Department may disseminate a list of ambulance services that require prior authorization to providers through manuals or bulletins. (c) The failure to obtain prior authorization shall result in denial of Medicaid payment for the service.
Section 10. Medicaid Allowable Payment. Medicaid reimbursement shall be the lesser of the provider's usual and customary charges and the Medicaid fee schedule.
(a) An ambulance trip report must be submitted with all claims. The failure to submit such a report may result in the denial of payment.
(b) An ambulance trip report is a written report, in the form and containing the information specified by the Department, documenting the ambulance services for which Medicaid reimbursement is being sought.
Section 12. Delegation of duties. The Department may delegate any of its duties under this rule to the HHS, any other agency of the federal, state or local government, or a private entity which is capable of performing such functions, provided that the Department shall retain the authority to impose sanctions, recover overpayments or take any other final action authorized by this Chapter or another Chapter within this rule.
(a) The order in which the provisions of this Chapter appear is not to be construed to mean that any one provision is more or less important than any other provision.
(b) The text of this Chapter shall control the titles of various provisions.
Section 14. Superseding Effect. This Chapter supersedes all prior rules or policy statements issued by the Department, including manuals and/or bulletins, which are inconsistent with this Chapter.
Section 15. Severability. If any portion of this Chapter is found invalid or unenforceable, the remainder shall continue in effect.