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Medical necessity

Not all insurance companies cover ambulance service and still others have very strict requirements before they are covered. The following are some general guidelines on what many insurance companies will cover. For specific information concerning what your insurance policy covers you are urged to contact your insurance agency or plan administrator.

In general, insurance companies will pay for emergency ambulance service. This usually includes transports to local emergency departments, if deemed medically necessary (see below). In general, it does NOT include transports to:

  • Physicians' or doctors' offices
  • Outpatient treatment facilities
  • Urgent care centers
  • Hospitals outside the immediate service area (Volusia County)
  • Other non-medical facilities

Many claims are denied for ambulance service because it has been determined by the insurance carrier that the services were not medically necessary. The standards by which medical necessity is determined vary from carrier to carrier. However, in general for the service to be determined medically necessary, the patient's medical condition must be such that any other means of transportation would have placed the patient's life in danger.

Medicare and Medicaid have very strict medically necessary guidelines. Effective October 1, 1999, all non-emergency ambulance transports from a hospital, nursing home, physician's office, out-patient facility or clinic will require the physician to sign a "Certificate of Medical Necessity" (CMN). If the CMN is not submitted to the ambulance service within 21 days of transport, including holidays and weekends, the claim must be submitted to Medicare as "Not Medically Necessary" resulting in the claim being denied and the patient responsible for the full amount of the ambulance bill. HMOs and other managed health care plans, on the other hand, require prior approval on "non-emergency" ambulance transportation and other restrictions may apply. For details, contact your insurance agent or plan.

 

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