Payment Policy Ambulance

Transcription

1 Payment Plicy Ambulance 01/01/ E Century Ave Ste 1 PO Bx 5585 Bismarck ND

2 Cpyright Ntice The five character cdes included in the Nrth Dakta Fee Schedule are btained frm the Current Prcedural Terminlgy (CPT), cpyright 2014 by the American Medical Assciatin (AMA). CPT is develped by the AMA as a listing f descriptive terms and five character identifying cdes and mdifiers fr reprting medical services and prcedures perfrmed by physicians. The respnsibility fr the cntent f Nrth Dakta Fee Schedules is with WSI and n endrsement by the AMA is intender r shuld be implied. The AMA disclaims respnsibility fr any cnsequences r liability attributable r related t any use, nnuse r interpretatin f infrmatin cntained in Nrth Dakta Fee Schedule. Fee Schedules, relative value units, cnversin factrs and/r related cmpnents are nt assigned by the AMA, are nt part f CPT and the AMA is nt recmmending their use. The AMA des nt directly r indirectly practice medicine r dispense medical services. The AMA assumes n liability fr data cntained r nt cntained herein. Any use f CPT utside f Nrth Dakta Fee Schedule shuld refer t the mst Current Prcedural Terminlgy which cntains the cmplete and mst current listing f CPT cdes and descriptive terms. Applicable FARS/DFARS apply. CPT is a registered trademark f the American Medical Assciatin. ADA cdes are cpyright 2014 American Dental Assciatin. All Rights Reserved. Reprduced and distributed under ADA License # Disclaimer Language The fact that a prcedure r service is assigned a HCPCS cde and a payment rate des nt imply cverage by WSI, but indicates nly hw the prcedure r service may be paid if cvered by the prgram. The existence f a prcedure cde n this list is nt a guarantee that the cde is cvered. Fr reference purpses, the sectins f the Nrth Dakta Administrative Cde that regulate medical services are thrugh The NDAC can be viewed at the Nrth Dakta Legislative Cuncil web site: CPT nly cpyright 2014 American Medical Assciatin. All rights reserved. 2

3 Table f Cntents Ambulance Payment Methdlgy... 4 Ambulance Payment Parameters... 5 Prvider Remittance Advice... 6 CPT nly cpyright 2014 American Medical Assciatin. All rights reserved. 3

4 Wrkfrce Safety & Insurance Ambulance Payment Methdlgy WSI fee schedules use the prcedure cdes and descriptins fund in the American Medical Assciatin s Current Prcedural Terminlgy (CPT ) manual. The WSI Ambulance Fee Schedule is based n the Medicare Ambulance Fee Schedule with sme exceptins, which are identified in Ambulance Payment Parameters. Histrically, WSI payment was based n the Unadjusted Base Payment Amunts. As a result, it des nt incrprate the current Medicare adjustments fr rural rigin vs. urban rigin, rural mileage vs. urban mileage, payment adjustments fr lnger miles, etc. The WSI Ambulance Fee Schedule als des nt incrprate Medicare s reginal rate t full natinal rate transitin. Ambulance Payment amunts are updated annually based n the CPI-U published by CMS. The increases are applied t the prir year s payment amunt. The update will apply t bth grund ambulance services and air ambulance services. Apprpriate adjustments are als made fr base rate weight changes (if necessary). WSI will assign ne f the fllwing 4 status cdes t each HCPCS cde: A Active Cde Will be paid under the WSI fee schedule B Bundled Cde Payment is bundled int the payment fr ther services C WSI Priced Cde Payment is made under WSI negtiated amunts r U&C amunts P Excluded Cde N payment is made fr these cdes CPT nly cpyright 2014 American Medical Assciatin. All rights reserved. 4

5 Wrkfrce Safety & Insurance Ambulance Payment Parameters The payments n the WSI Ambulance Fee Schedule are based largely n Medicare s Ambulance Fee Schedule. Therefre, WSI has adpted many f the Medicare ambulance payment parameters. Hwever, sme differences between the Medicare ambulance payment prvisins and the WSI ambulance payment prvisins exist. These are listed belw: Prviders will be required t use the current established HCPCS cdes fr ambulance services Prviders will be required t bill using the same medical necessity guidelines as they use fr Medicare WSI will fllw Medicare s payment reductin rules fr ambulance runs with multiple patients n bard WSI will fllw Medicare s payment prvisins when a patient is prnunced dead after the ambulance has been called but befre the ambulance arrives WSI will make payment fr the base service and laded mileage nly The payment fr supplies, drugs, xygen and miscellaneus services will be bundled int the payment fr the base service Waiting time charges will be bundled int the payment fr the base service WSI will accept, but will nt require, ZIP Cde reprting WSI will accept, but will nt require, fractinal mileage billing WSI will require the use f mdifiers as fllws WSI will require the use f the GM and QL mdifiers WSI will accept, but will nt require, the use f rigin and destinatin mdifiers WSI will accept, but will nt require, the use f under arrangement mdifiers. CPT nly cpyright 2014 American Medical Assciatin. All rights reserved. 5

6 Wrkfrce Safety & Insurance Prvider Remittance Advice WSI prcesses medical service billings weekly. A remittance advice is sent t the prvider with the reimbursement check, prviding infrmatin t the prvider abut the service, including the patient's name, date f service, prcedure billed, submitted amunt, and paid amunt. The remittance advice als includes reasn cdes r explanatin f benefits (EOB) cdes, t explain any reductins in payment f a service r denial f payment. Sme EOB cdes allw the patient t be billed fr the denied charges, r fr the balance f reduced charges. These instances are identified by the statement "CONTACT CLAIMANT FOR PAYMENT". When these EOB cdes ccur, WSI als sends a "NOTICE OF NON-PAYMENT" EOB t the patient regarding the reduced r denied charges, t infrm the patient f their respnsibility fr the charges. If an EOB cde des nt state the patient may be cntacted fr payment, any reductin r denial f services is nt billable t the patient, the emplyer, r anther insurer. The cmplete listing f ur EOB cdes can be fund n ur website under the frms library, r by fllwing the link prvided belw. Cpies f remittance advice can be btained by calling CPT nly cpyright 2014 American Medical Assciatin. All rights reserved. 6