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Coverage criteria policies

Ambulance and medical transportation - Minnesota Health Care Programs

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 documents will be used to determine your coverage.

Administrative Process

Prior authorization is required for air ambulance transportation originating outside of Minnesota or going to a destination outside of Minnesota or its local trade area.

Prior authorization is not required for ground ambulance.

Coverage

Ambulance transportation is generally covered subject to the indications listed below and per your plan documents.

All other transportation, including Access Transportation Services (common carrier) and Special Transportation Services do not require authorization.

Note:

  • To request prior authorization for air ambulance services or transportation to return to the service area call 952-883-6277 or 1-800-255-1886 (ext. 36277). There is voicemail 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 Case Management.
  • 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.

Indications that are covered

  1. Eligible providers must be licensed as a transportation service provider for advanced life support, basic life support, or scheduled life support.
  2. Ambulance services are covered when the recipient’s transportation is for the following:
    1. In response to:
      1. A 911 emergency call
      2. A police or fire department call
      3. An emergency call received by the provider
    2. Between two facilities, only when the first facility discharges the recipient to another facility because the first facility could not provide the level of care required by the recipient
    3. Medically necessary
  3. A transfer of an infant from an NICU level II or III nursery to a hospital near the family’s home, if the distance from the NICU facility to the family home is greater than 40 miles
  4. Transportation is covered according to the following if a recipient is pronounced dead by a legally authorized person:
    1. After transportation is called, but before it arrives, service to the point of pickup is covered
    2. En route, or dead on arrival, the transportation is covered
    3. Before transportation is called, transportation is not covered
  5. Ambulance no-load transportation is covered only if the ambulance transportation staff provided medically necessary treatment to the recipient at the pickup point.
  6. Air ambulance is covered when the following criteria are met:
    1. The recipient has a potentially life-threatening condition that does not permit the use of another form of ambulance transportation
    2. The referring facility does not have adequate facilities to provide the medical services needed by the recipient
    3. Transport must be to the nearest appropriate facility capable of providing the level of care required by the recipient
    4. All air ambulance transportation originating outside of or going to a destination outside of Minnesota or its local trade area must meet one of the following:
      1. The services are provided in response to an emergency while the member is out of Minnesota or its local trade area
      2. The services are not available in Minnesota or its local trade area, and the attending physician has determined medical necessity and obtained prior authorization
      3. The services are required because the member’s health would be endangered if he/she were required to return to Minnesota for treatment.
  7. Ground ambulance is covered when the following criteria are met:
    1. The recipient has a potentially life-threatening condition that does not permit the use of another form of transportation
    2. Service is medically necessary
    3. The referring facility does not have adequate facilities to provide the medical services needed by the recipient
    4. Transport must be to the nearest appropriate facility by the most direct route
  8. Non-emergency transport (NEMT) services are covered when provided for an eligible MHCP member to or from the site of an covered medical service and either of the following apply:
    1. Services are provided by an enrolled MHCP health care provider (ambulance and state-administered NEMT)
    2. Services are provided by a local county services or tribal agency provider (local agency-administered NEMT)

Definitions

Ambulance Transportation Services is the transport of a recipient whose medical condition or diagnosis requires medically necessary services before and during transport. This includes air and ground, emergency and nonemergency ambulance services.

Minnesota Local Trade Area includes Minnesota and the counties of neighboring states that are contiguous with Minnesota.

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. Minnesota Health Care Programs (MHCP) Provider Manual: Ambulance Transportation Services. Revised 01-13-2017.
  2. Minnesota Health Care Programs (MHCP) Provider Manual: Out of State Services. Revised 10-23-2018.
  3. Minnesota Health Care Programs (MHCP) Provider Manual: Nonemergency Medical Transportation (NEMT) Services. Revised 10-22-2018.

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Policy activity

  • 04/01/2016 - Date of origin
  • 02/01/2019 - Effective date
Review date
  • 02/2019
Revision date
  • 01/18/2019

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