CHAPTER 15

 

AMBULANCE SERVICES

 

Section 1.Authority

 

This Chapter is promulgated by the Department of Health pursuant to the Medical Assistance and Services Act at Wyoming Statutes §§ 42-4-101 through -306.

 

Section 2.Purpose and Applicability.

 

This rule establishes the scope for ambulance services covered by Medicaid and the methods and standards for reimbursing providers for such services.

 

Section 3.Incorporation By Reference

 

(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 in this rule is further identified as follows:

 

(i)                 Referenced in Section 7 of this Chapter are Chapters 0 - 15 of the Wyoming Department of Health, Emergency Medical Services Rules, incorporated as of the effective date of this Chapter and found at https://rules.wyo.gov.

 

   Section 4.General Terms

 

(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 Wyoming Medicaid Rule, Chapter 1, the terminology used in this Chapter is the standard terminology and has the standard meaning used in healthcare, Medicaid, and Medicare.

 

Section 6.Provider Participation.

 

(a)Eligible providers. In order to be an eligible provider under this Chapter, an individual or entity shall:

 

(i)                 Hold a current ambulance business license pursuant to the Wyoming Emergency Medical Services Act of 1977, found at Wyoming Statues §§ 33-36-101 through 115, or, if the provider is located outside Wyoming, is licensed under applicable provisions of that state's law; and

 

(ii)               Meet all Medicare certification requirements.

 

(b)               Compliance with Wyoming Medicaid Rule, Chapter 3 - Provider Participation. A person or entity that wishes to receive Medicaid reimbursement for covered services furnished to a recipient shall meet the provider participation requirements of Wyoming Medicaid Rule, Chapter 3.

 

(c)Right of inspection. The Office of Emergency Medical Services 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 that 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.

 

Section 7.Covered Services.

 

The terms in this section shall be interpreted under the definitions and classifications established by the Office of Emergency Medical Services Rules.

 

(a)                Emergency ground ambulance transportation is a covered service.

(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, but not limited to, 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 in accordance with Wyoming Emergency Medical Services Rules certifying them to perform additional procedures including, but not limited, to cardiac monitoring and defibrillation, advanced airway management, intravenous therapy, and the administration of medications.

(A)             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 shall meet licensure standards for ALS care. 

(I)                   An ALS intervention refers to the provision of care outside the scope of a basic EMT and shall be medically necessary.

(B)              Advanced Life Support Level 2 (ALS2) is 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, the provision of medically necessary supplies and services, and at least one of the ALS2 procedures listed below:

(I)Manual defibrillation/cardio version;

(II)Endotracheal intubation;

(III)Central venous line;

(IV)Cardiac pacing;

(V)Chest decompression;

(VI)Surgical airway; or

(VII)Intraosseous line.

(iii)ALS or BLS ground ambulance is a covered service if:

(A)             The use of any other method of transportation would endanger the health of the client;

 

(B)              The client is transported to the nearest appropriate facility which offers services sufficient to meet the medical needs of the client;

 

(C)              The client is admitted to the receiving facility as an inpatient or an outpatient;

(D)             The service is medically necessary; and

 

(E)              The service was actually rendered to the

(iv)             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 is:

 

(i)                 Continuously dependent on oxygen;

 

(ii)               Continuously confined to bed;

 

(iii)            Unable to perform any physical activity without discomfort because of a cardiac disease;

 

(iv)             Receiving intravenous treatment;

 

(v)               Heavily sedated;

 

(vi)             Comatose;

 

(vii)           Post pneumo/encephalogram, myelogram, spinal tap, or cardiac catheterization;

 

(viii)        Unable to have flexion at the hip because of hip spicas or other casts;

 

(ix)             In need of isolette in perinatal period; or

 

(x)               Unconscious or semi-conscious.

 

(d)               Advanced Life Support Level 1- Non-Emergent (ALS1- non-emergent) in non-emergent circumstances.

 

(i)                 ALS1 - non-emergent is a covered service if the requirements in Section 7(b)(iii) of this Chapter are met.

 

(e)                Air ambulance services are covered when:

 

(i)                 Services are provided by a fixed-wing aircraft or helicopter licensed to provide ambulance services, and 

 

(ii)               One of the following requirements is met:

 

(A)             The client has a life-threatening condition and the use of any other method of transportation, including ground ambulance, would endanger the health of the client;

 

(B)              The client's location is inaccessible by ground ambulance; or

 

(C)              Air transport is more cost effective than any alternative method of transportation.

 

(f)                Community Emergency Medical Services, as described and certified by the Office of Emergency Medical Services (OEMS), includes Community Emergency Medical Services - Technician (CEMS-T) and Community Emergency Medical Services - Clinician (CEMS-C).  Community Emergency Medical Services are a covered service if the requirements in this section are met:

 

(i)                 Community Emergency Medical Services - Technician (CEMS-T)

 

(A)             Providers (both the agency and the individual) shall have a current endorsement of CEMS-T from the Office of Emergency Medical Services.

 

(B)              Services shall be provided in response to a call for service and include:

(I)     Appropriately treating and releasing clients, rather than providing transportation to a hospital or emergency department;

 

(II)Treating and transporting clients to appropriate destinations other than a hospital or an emergency department;

 

(III)Treatment and referral to a primary care or urgent care facility; or

(IV)Assessment of the client and reporting to a primary care provider to determine an appropriate course of action.

 

(C)              Provider documentation shall be entered into the electronic reporting system maintained by the OEMS and fully document services provided to the client.

 

(ii)               Community Emergency Medical Services - Clinician (CEMS-C)

 

(A)             Providers (both the agency and the individual) shall have a current endorsement of CEMS-C from the Office of Emergency Medical Services.

 

(B)              Services provided by the CEMS-C certified provider shall be:

 

(I)Within the scope of practice for the license held by the CEMS-C provider;

 

(II)Provided under the direct written or verbal order of a physician;

 

(III)Services that are likely to prevent admission to a hospital, nursing home, or other institutionalized care setting;

 

(IV)Coordinated with care received by the client from other community providers in order to prevent duplication of services; and

 

(V)Identified in a written, well documented plan of care, which may include:

 

(1.)             Health assessments;

 

(2.)             Chronic disease monitoring and education;

 

(3.)             Medication compliance;

 

(4.)             Immunizations and vaccinations;

 

(5.)             Laboratory specimen collection;

 

(6.)             Hospital discharge follow-up care; and

 

(7.)             Minor medical procedures.

 

(C)              Services provided, physician's orders, and the plan of care shall be documented in the client's comprehensive medical record maintained by the ambulance agency and supplied to the Department upon request.

 

 

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 at the request of the client or family;

 

(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);

 

(n)Paramedic Intercept (PI);

 

(o)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; and

 

(p)Any other service not included in Section 7 of this Chapter.

 

Section 9.Prior Authorization.

 

(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.

 

Section 11. Submission and Payment of Claims.

 

(a)                An ambulance trip report shall be submitted with all claims. The failure to submit such a report may result in the denial of payment. 

 

(i)                 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.

 

 Section 13.     Interpretation of Chapter.

 

(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 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.