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Coverage criteria policies

Ambulance Transportation Services-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. Air ambulance if all of the following 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. Services out of Minnesota or out of the local trade area must meet one of the following:
      1. The services are provided in response to an emergency while the recipient 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 recipient's health would be endangered if he/she were required to return to Minnesota for treatment.
  2. Ground ambulance if all of the following 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.
  3. Ground ambulance for non-emergency transports that are medically necessary to meet the needs of the recipient.

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. Ambulance Transportation Services-MHCP Provider Manual http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=dhs16_141022
  2. Out of state Services-MHCP Provider Manual http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=id_008925#P179_11980

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Policy activity

  • 04/01/2016 - Date of origin
  • 02/01/2017 - Effective date
Review date
  • 02/2017

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