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HealthPartners

Coverage criteria policies

Ambulance and medical transportation

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan will be used to determine your coverage.

Administrative Process

  • Fixed wing air ambulance services requires prior approval via HealthPartners Disease & Case Management Department.
  • Ground ambulance and rotary wing air ambulance transportation services do not require prior approval.

Note:

  • To request prior approval for fixed wing air ambulance services call 952-883-6277 or 1-800-255-1886 (ext. 36277). There is voicemail service available 24 hours a day/7 days a week.
  • If you are calling Monday-Friday, 8:00am to 5:00pm CST (excluding national holidays), you may call the above numbers and press 0# to talk to someone in HealthPartners Disease & Case Management Department.
  • If the situation is urgent and it is outside regular business hours, call the CareLine 612-339-3663, toll free (US and Canada) 1-800-551-0859.

Coverage

Ambulance and medical transportation is covered for medical emergencies and as per the indications listed below.

Indications that are covered

Rotary Wing Air Ambulance Transportation (helicopter)

Rotary wing air ambulance transportation services are covered when medically necessary as set forth below:

  1. Rotary wing air ambulance transportation services may be medically necessary when all of the following criteria are met:
    1. The patient’s transport could not have been provided by ground ambulance or the point of pickup is not accessible by ground ambulance; and
    2. The patient’s medical condition is such that the time needed to transport the patient by ground poses a threat to the patient’s survival or seriously endangers the patient’s health. Examples of cases for which rotary wing air ambulance may be medically necessary include, but are not limited to the following:
      1. Trauma center intervention required,
      2. Intracranial bleeding requiring neurosurgical intervention;
      3. Major burns requiring immediate treatment in a burn center;
      4. Limb threatening trauma;
      5. Shock, sepsis, or organ failure with immediate life-threatening implications requiring tertiary care;
      6. Patients with near-drowning injuries; and
    3. The patient is transported to the nearest hospital with the appropriate facilities based upon the patient’s injuries and condition.
  2. Rotary wing air ambulance transportation to the next nearest facility may be medically necessary when:
    1. Criteria 1a and 1b are met; and
    2. The first hospital does not have the required services or facilities to treat the patient.
  3. Rotary wing air ambulance transportation of a trauma victim by air from a community hospital to a tertiary center such as a level I-II trauma center may be medically necessary when initial evaluation at the community hospital reveals injuries or potential injuries requiring further evaluation and management beyond the capabilities of the referring hospital.

Fixed Wing Air Ambulance Transportation

Fixed wing air ambulance services may be medically necessary when all of the following criteria are met:

  1. Great distances, limited timeframes, or other obstacles are involved in transporting the patient by ground ambulance to the hospital; and
  2. The patient’s medical condition is such that the time needed to transport the patient by ground ambulance poses a threat to the patient’s survival or seriously endangers the patient’s health; and
  3. The patient's medical condition requires uninterrupted care and attendance by qualified medical staff during ambulance transport; and
  4. The hospital the patient is being transferred to has the appropriate medical equipment to meet the patient’s needs; and
  5. Transport is to the nearest facility capable of treating the patient’s condition; supporting documentation is required; and
  6. The patient’s medical condition requires specialty care not available at the hospital where the patient is currently receiving care. Examples include but are not limited to:
    1. Critically ill medical, cardiac or surgical patients requiring medical care not available at the referring hospital;
    2. Neonate requiring a specialized neonatal team during transport and ground ambulance transport is not feasible within a reasonable time frame;
    3. Organ transplant recipient requires air transport with medical intervention to the appropriate approved transplant facility.

Other Covered Indications

  1. Ground ambulance for medical emergency situations.
  2. Medically necessary emergency medical care provided by ground ambulance service when the member is not transported to a hospital.
  3. Transfers from a hospital or at home to other facilities by ground ambulance when medical supervision is required en route.
  4. Transfers by ground ambulance when the first hospital does not have the required services or facilities to treat the patient.
  5. Care provided by first responders. Examples include but are not limited to a rural area where the fire department arrives first and stabilizes the patient’s condition. The patient may then be taken to the ER by a family member or an ambulance once the patient is stable enough for transport. The care given by the fire department would be covered.
Indications that are not covered
  1. Transfers from home or a covered skilled nursing facility (SNF) to a physician’s office or other facilities for outpatient treatment, procedures or tests.
  2. Transportation from a hospital that is capable of treating the patient to another hospital primarily for the convenience of the patient or patient’s family, physician or other health care provider.
  3. Transportation by air when ground transportation is available and the time required to transport the patient by ground does not endanger the patient's life or health.
  4. Transportation of a deceased patient when the patient was pronounced dead at the scene.
  5. Transportation to a facility that is not an acute care hospital with appropriate facilities to treat the condition for which the transfer was made.
  6. Transportation related to search and rescue operations.
  7. Transportation to a facility that is not the closest location capable of providing the level of care required.

Definitions

Fixed Wing Air Ambulance: This aircraft is an airplane, jet, or turbo prop plane that is able to travel longer distances than its counterpart, the rotary wing air ambulance (i.e. the helicopter). .

Rotary Wing Air Ambulance: This aircraft is a helicopter that is able to provide the advantage of rapid, direct access to the scene. These are reserved for short-range transports and those instances where ground ambulance transport would result in unacceptable delays.

Ground Ambulance: Transportation via road by a basic life support or advanced life support ambulance.

First responder is a term applied to the fist individual who arrives at the scene or an emergency. The first responder uses a limited amount of equipment to perform initial assessment and intervention and is trained to assist other emergency medical services providers.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

References

  1. Medicare Ambulance Services Center - http://www.cms.gov/Center/Provider-Type/Ambulances-Services-Center.html
  2. Thomson, D.P., Thomas, S.H. (2003). Position paper national association of ems physicians. Guidelines for air medical dispatch. Prehospital Emergency Care. 7(2):265-271.

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Policy activity

  • 07/01/1995 - Date of origin
  • 05/01/2018 - Effective date
Review date
  • 02/2018
Revision date
  • 05/07/2018

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