Purpose: The department is adopting amended and new rules to improve readability, clarify policy regarding emergency transportation services, and streamline program administration by making MAA's policy more consistent with Medicare's policy where practicable.

     Citation of Existing Rules Affected by this Order: Amending WAC 388-546-0001, 388-546-0100, 388-546-0150, 388-546-0200, 388-546-0250, 388-546-0300, 388-546-0400, 388-546-0450, 388-546-0500, 388-546-0600, 388-546-0700, 388-546-0800, and 388-546-1000.

     Statutory Authority for Adoption: RCW 74.04.057, 74.08.090, and 74.09.510.

      Adopted under notice filed as WSR 04-12-103 on June 2, 2004.

     Changes Other than Editing from Proposed to Adopted Version: The following changes, other than editing changes, have been made to the rules as proposed (Additions indicated by underlined text, deletions indicated by strikethrough text):

REVISED SECTIONS:

WAC 388-546-0001 Definitions. "Bordering area city hospital" means a licensed hospital in a designated bordering city (see WAC 388-501-0175).

WAC 388-546-2500 Transportation to or from out-of-state treatment facilities--Coordination of benefits. (1) The medical assistance administration (MAA) does not pay for a client's transportation to or from an out-of-state treatment facility when the medical service, treatment, or procedure sought by the client is available from an in-state facility or in a designated bordering city, whether or not the client has other insurance coverage.

     (2) For clients who are otherwise eligible for out-of-state coverage under WAC 388-546-0150, but have other third-party insurance, MAA does not pay for transportation to or from out-of-state treatment facilities when the client's primary insurance:

     (a) Denies the client's request for medical services out-of-state for lack of medical necessity; or

     (b) Denies the client's request for transportation for lack of medical necessity.

     (3) For clients who are otherwise eligible for out-of-state coverage under WAC 388-546-0150, but have other third-party insurance, MAA does not consider requests for transportation to or from out-of-state treatment facilities unless the client has tried all of the following:

     (a) Requested coverage of the benefit from his/her primary insurer and been denied;

     (b) Appealed the denial of coverage by the primary insurer; and

     (c) Exhausted his/her administrative remedies through the primary insurer.

     (4) If MAA authorizes transportation to or from an out-of-state treatment facility for a client with other third-party insurance, MAA's liability is limited to the cost of the least costly means of transportation that does not jeopardize the client's health, as determined by MAA in consultation with the client's referring physician.

     (5) For clients eligible for out-of-state coverage but have other third-party insurance, MAA considers requests for transportation to or from out-of-state treatment facilities under the provisions of WAC 388-501-0165.

     A final cost-benefit analysis is available by contacting Wendy Boedigheimer, P.O. Box 45533, Olympia, WA 98504-5533, phone (360) 725-1306, fax (360) 586-9727, e-mail boediwl@dshs.wa.gov.

     Number of Sections Adopted in Order to Comply with Federal Statute: New 1, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.

     Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 5, Amended 13, Repealed 0.

     Number of Sections Adopted Using Negotiated Rule Making: New 0, Amended 0, Repealed 0;      Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 6, Amended 13, Repealed 0.

     Date Adopted: August 13, 2004.

Brian H. Lindgren, Manager

Rules and Policies Assistance Unit

     "Advanced life support (ALS)" means that level of care that calls for invasive emergency medical services requiring advanced medical treatment skills.

     "Advanced life support (ALS) assessment" means an assessment performed by an ALS crew as part of an emergency response that was necessary because the client'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 client requires an ALS level of service.

     "Advanced life support (ALS) intervention" means a procedure that is beyond the scope of care of an emergency medical technician (EMT).

     "Aid vehicle" means a vehicle used to carry aid equipment and individuals trained in first aid or emergency medical ((procedure)) procedures.

     "Air ambulance" means a ((rotary blade ())helicopter(())) or ((fixed-wing aircraft ())airplane(())) designed and used to provide transportation for the ill and injured, and to provide personnel, facilities, and equipment to treat ((patients)) clients before and during transportation. Air ambulance is considered an ALS service.

     "Ambulance" means a ground or air vehicle designed((, licensed per RCW 18.73.140)) and used to provide transportation to the ill and injured; and to provide personnel, facilities, and equipment to treat ((patients)) clients before and during transportation; and licensed per RCW 18.73.140.

     "Base rate" means the medical assistance administration's (MAA) minimum ((reimbursement)) payment amount per covered trip, which includes allowances for emergency medical personnel and their services, the costs of standing orders, reusable supplies and equipment, hardware, stretchers, ((some)) oxygen and oxygen administration, intravenous supplies and IV administration, disposable supplies, normal waiting time, and the normal overhead costs of doing business. The base rate excludes mileage ((and MAA specified disposable supplies that can be billed separately)).

     "Basic life support (BLS)" means that level of care that justifies ambulance transportation but requires only basic medical treatment skills. It does not include the need for or delivery of invasive medical procedures/services.

     "Bed-confined" means the client is unable to perform all of the following actions:

     (1) Get up from bed without assistance;

     (2) Ambulate; and

     (3) Sit in a chair or wheelchair.

     "Bordering city hospital" means a licensed hospital in a designated bordering city (see WAC 388-501-0175).

     "Broker" (see "transportation broker").

     "Brokered transportation" means ((nonemergent)) nonemergency transportation arranged by a broker, under contract with MAA, to or from covered medical services for an eligible client (also, see "transportation broker").

     (("Border area hospitals" (see WAC 388-501-0175).))

     "By report" means a method of payment in which MAA determines the amount it will pay for a service that is covered but does not have an established maximum allowable fee. Providers must submit a report describing the nature, extent, time, effort, and/or equipment necessary to deliver the service.

     "Emergency medical service" means medical treatment and care that may be rendered at the scene of any medical emergency or while transporting any ((patient)) client in an ambulance to an appropriate medical facility, including ambulance transportation between medical facilities.

     "Emergency medical transportation" means ambulance transportation during which a client receives needed emergency medical services en route to an appropriate medical facility.

     (("Fixed wing aircraft" means an airplane.))

     "Ground ambulance" means a ground vehicle (including a water ambulance) designed and ((primarily)) used to provide transportation to the ill and injured and to provide personnel, facilities, and equipment to treat ((patients)) clients before and during transportation.

     "Invasive procedure" means a medical intervention that intrudes on the client's person or breaks the skin barrier.

     "Lift-off fee" means either of the two base rates MAA pays to air ambulance providers for transporting a client. MAA establishes ((one liftoff fee for rotary aircraft and one liftoff fee for fixed wing aircraft)) separate lift-off fees for helicopters and airplanes.

     "Loaded mileage" means the number of miles the client is transported in the ambulance vehicle.

     "Medical control" means the medical authority upon whom an ambulance provider relies to coordinate prehospital emergency services, triage and trauma center assignment/destination for the person being transported. The medical control is designated in the trauma care plan by the approved medical program director of the region in which the service is provided.

     "((Nonemergent)) Nonemergency ambulance transportation" means the use of a ground ambulance to carry a client who may be confined to a stretcher but typically does not require the provision of emergency medical services en route, or the use of an air ambulance when prior authorized by MAA. ((Nonemergent)) Nonemergency ambulance transportation is usually scheduled or prearranged. See also "prone or supine transportation," and "scheduled transportation."

     "Point of destination" means a facility generally equipped to provide the needed medical or nursing care for the injury, illness, symptoms, or complaint involved.

     "Point of pick-up" means the location of the client at the time he or she is placed on board the ambulance or transport vehicle.

     "Prone or supine transportation" means transporting a client confined to a stretcher or gurney, with or without emergency medical services being provided en route.

     (("Rotary blade aircraft" means a helicopter.))

     "Scheduled transportation" means prearranged transportation for an eligible client, typically in a vehicle other than an ambulance, with no emergency medical services being required or provided en route to ((and)) or from a covered medical service.

     "Specialty care transport (SCT)" means interfacility transportation of a critically injured or ill client by a ground ambulance vehicle, including medically necessary supplies and services, at a level of service beyond the scope of the paramedic.

     "Standing order" means an order remaining in effect indefinitely until canceled or modified by an approved medical program director (regional trauma system) or the ambulance provider's medical control.

     "Transportation broker" means a person or organization contracted by MAA to arrange, coordinate and manage the provision of necessary but ((nonemergent)) nonemergency transportation services for eligible clients to and from covered medical services.

     "Trip" means transportation one-way from the point of pick-up to the point of destination by an authorized transportation provider.

[Statutory Authority: RCW 74.08.090, 74.09.500, 74.04.050, 74.04.055, and 74.04.057. 01-03-084, § 388-546-0001, filed 1/16/01, effective 2/16/01.]

     (2) The medical assistance administration (MAA) covers medically necessary ambulance transportation to and from the provider of MAA covered services that is closest and most appropriate to meet the client's medical need. See WAC 388-546-0150 through ((388-546-1000)) 388-546-4000 for ambulance transportation and WAC 388-546-5000 through 388-546-5600 for brokered/nonemergency transportation. ((See WAC 388-546-0150 for client eligibility for ambulance transportation. See WAC 388-546-5100 for client eligibility for brokered/nonemergency transportation.))

[Statutory Authority: RCW 74.08.090, 74.09.500, 74.04.050, 74.04.055, and 74.04.057. 01-03-084, § 388-546-0100, filed 1/16/01, effective 2/16/01.]

     (b) The general assistance - unemployable program)) Except for clients in the Family Planning Only program, MAA fee-for-service clients are eligible for ambulance transportation to MAA covered services with the following limitations:

     (a) Clients in the following programs are eligible for ambulance services within Washington state or bordering cities only, as designated in WAC 388-501-0175:

     (i) General assistance-unemployable (GA-U);

     (ii) General assistance-expedited medical (GA-X);

     (iii) General assistance-pregnancy (GA-S);

     (iv) Alcoholism and Drug Addiction Treatment and Support Act (ADATSA);

     (v) Emergency medical programs, including alien emergency medical (AEM);

     (vi) LCP-MNP emergency medical only; and

     (vii) State Children's Health Insurance Program (CHIP) when the client is not enrolled in a managed care plan.

     (b) Clients in the categorically needy/qualified Medicare beneficiary (CN/QMB) and medically needy/qualified Medicare beneficiary (MN/QMB) programs are covered by Medicare and Medicaid, with the payment limitations described in WAC 388-546-0400(5).

     (2) Clients enrolled in an MAA managed care plan receive all ambulance services through their designated plan, subject to the plan's coverages and limitations.

     (3) Clients enrolled in MAA's primary care case management (PCCM) program are eligible for ambulance services that are emergency medical services or that are approved by the PCCM in accordance with MAA requirements. MAA pays for covered services for these clients according to MAA's published billing instructions.

     (4) Clients under the Involuntary Treatment Act (ITA) are not eligible for ambulance transportation coverage outside the state of Washington. This exclusion from coverage applies to individuals who are being detained involuntarily for mental health treatment and being transported to or from bordering cities. See also WAC 388-546-4000.

     (5) See WAC 388-546-0800 and 388-546-2500 for additional limitations on out-of-state coverage and coverage for clients with other insurance.

     (6) Jail inmates and persons living in a correctional facility are not eligible for MAA ambulance coverage. See WAC 388-503-0505(5).

[Statutory Authority: RCW 74.08.090, 74.09.500, 74.04.050, 74.04.055, and 74.04.057. 01-03-084, § 388-546-0150, filed 1/16/01, effective 2/16/01.]

     (a) Within the scope of an eligible client's medical care program (see chapter 388-529 WAC, Scope of medical services);

     (b) Medically necessary as defined in WAC 388-500-0005 based on the client's condition at the time of the ambulance trip and as documented in the client's record;

     (((b))) (c) Appropriate to the client's actual medical need;

     (((c) Documented in the provider's client record as to medical necessity;)) and

     (d) To one of the following destinations:

     (i) The ((closest)) nearest appropriate MAA-contracted medical provider of MAA-covered services; or

     (ii) The designated trauma facility as identified in the emergency medical services and trauma regional patient care procedures manual.

     (2) MAA limits coverage to ((that)) medically necessary ambulance transportation that is required because the client cannot be safely or legally transported any other way. If a client can safely travel by car, van, taxi, or other means, the ambulance trip is not medically necessary and the ambulance service is not covered by MAA. See WAC 388-546-0250 (1) and (2) for ((MAA's process for determining medical necessity)) noncovered ambulance services.

     (3) If Medicare or another third party is the client's primary health insurer and that primary ((party)) insurer denies coverage of an ambulance trip due to a lack of medical necessity, MAA requires the provider ((to report)) when billing MAA for that trip to:

     (a) ((That)) Report the third party determination on the ((billing to MAA)) claim; and

     (b) ((A justification for the trip)) Submit documentation showing that the trip meets the medical necessity criteria of MAA. See WAC 388-546-1000 and 388-546-1500 for requirements for nonemergency ambulance coverage.

     (4) MAA covers the following ambulance transportation ((for its eligible clients)):

     (a) ((Emergency medical transportation by air ambulance when justified under the conditions of this chapter; and

     (b) Medical transportation by)) Ground ambulance when the eligible client:

     (i) Has an emergency medical need for the transportation;

     (ii) Needs medical attention to be available during the trip; or

     (iii) Must be transported by stretcher or gurney.

     (b) Air ambulance when justified under the conditions of this chapter or when MAA determines that air ambulance is less costly than ground ambulance in a particular case. In the latter case, the air ambulance transportation must be prior authorized by MAA. See WAC 388-546-1500 for nonemergency air ambulance coverage.

     (((5) MAA covers (through the healthy options managed care plan) medically necessary ambulance transportation for clients enrolled in the plan. This coverage is included in the prepaid plan premium (see WAC 388-546-0400(2)).

     (6) MAA covers medically necessary ambulance transportation for clients enrolled in MAA's primary care case management (PCCM) program. Ambulance services that are emergency medical services or that are approved by the PCCM in accordance with MAA requirements are reimbursed by MAA according to MAA's published billing instructions.

     (7) MAA covers ambulance trips transporting patients from one hospital to another when the transferring or discharging hospital has inadequate facilities to provide the necessary medical services required. MAA covers air ambulance transportation for hospital transfers only if transportation by ground ambulance would endanger the client's life or health.))

[Statutory Authority: RCW 74.08.090, 74.09.500, 74.04.050, 74.04.055, and 74.04.057. 01-03-084, § 388-546-0200, filed 1/16/01, effective 2/16/01.]

     (3))) The medical assistance administration (MAA) does not cover ambulance services when the transportation is:

     (a) Not medically necessary based on the client's condition at the time of service (see exception at WAC 388-546-1000);

     (b) Refused by the client (see exception for ITA clients in WAC 388-546-4000(2));

     (c) For a client who is deceased at the time the ambulance arrives ((on-)) at the scene;

     (d) For a client who dies after the ambulance arrives ((on-)) at the scene but prior to transport and the ambulance crew ((did not provide significant)) provided minimal to no medical ((services on-)) interventions/supplies at the scene (see WAC 388-546-0500(2));

     (e) Requested for the convenience of the client or the client's family;

     (f) More expensive than ((arranging to bring)) bringing the necessary medical ((service)) service(s) to the client's location in nonemergency situations;

     (g) To transfer a client from a medical facility to the client's ((home (see exception at WAC 388-546-1000))) residence (except when the residence is a nursing facility);

     (h) Requested solely because a client has no other means of transportation;

     (i) Provided by other than licensed ambulance providers (e.g., wheelchair vans, cabulance, stretcher cars); or

     (j) Not to the nearest appropriate medical facility (((e.g., the client's destination is an urgent care clinic or freestanding outpatient facility rather than a hospital emergency room) (see exception at WAC 388-546-1000).

     (4) MAA does not cover ambulance services for hospital to hospital transportation if the transportation is requested:

     (a) To accommodate a physician's or other health care provider preference for facilities;

     (b) To move the client closer to family or home (e.g., for personal convenience); or

     (c) To meet insurance requirements or hospital/insurance agreements)).

     (2) If transport does not occur, MAA does not cover the ambulance service, except as provided in WAC 388-546-0500(2).

     (3) MAA evaluates requests for services that are listed as noncovered in this chapter under the provisions of WAC 388-501-0160.

     (4) For ambulance services that are otherwise covered under this chapter but are subject to one or more limitations or other restrictions, MAA evaluates, on a case-by-case basis, requests to exceed the specified limits or restrictions. MAA approves such requests when medically necessary, in accordance with WAC 388-501-0165.

     (5) An ambulance provider may bill a client for noncovered services as described in this section, if the requirements of WAC 388-502-0160 are met.

[Statutory Authority: RCW 74.08.090, 74.09.500, 74.04.050, 74.04.055, and 74.04.057. 01-03-084, § 388-546-0250, filed 1/16/01, effective 2/16/01.]

     (2) ((Air and ground)) Ambulances must be staffed and operated by appropriately trained and certified personnel. Personnel who provide any invasive procedure/emergency medical services for a client during an ambulance trip must be properly authorized and trained per RCW 18.73.150 and 18.73.170.

     (3) The medical assistance administration (MAA) requires providers of ambulance services to ((show)) document medical justification ((on billing documents)) for transportation and related services((/supplies)) billed to MAA. Documentation in the provider's client record must include adequate descriptions of the severity and complexity of the client's condition (including the circumstances that made the conditions acute and emergent) at the time of the transportation. MAA may review the client record to ensure MAA's criteria ((are)) were met.

[Statutory Authority: RCW 74.08.090, 74.09.500, 74.04.050, 74.04.055, and 74.04.057. 01-03-084, § 388-546-0300, filed 1/16/01, effective 2/16/01.]

     (2) MAA does not ((reimburse)) pay providers ((directly)) under fee-for-service for ambulance services provided to a client who is enrolled in an MAA ((Healthy Options)) managed care plan. Payment in such cases is the responsibility of the prepaid managed care plan.

     (3) MAA ((includes certain covered ambulance services in its payments to inpatient hospitals. MAA does not reimburse ambulance providers for ambulance transportation services if the client remains as an inpatient in a hospital and the transportation is for temporary transfer to another facility for diagnostic or treatment services (e.g., MRI scanning, kidney dialysis). Transportation of an inpatient for such services is included in MAA's payment to the hospital. It is the responsibility of the hospital where the client is an inpatient to reimburse ambulance providers for these transports.

     (4) MAA reimburses for the actual mileage incurred for covered trips by paying from the client's point of origin to the point of destination. MAA does not reimburse mileage for any distances traveled to the pick-up point or any other distances traveled when the client is not on board the ambulance.

     (5))) does not pay providers for mileage incurred traveling to the point of pick-up or any other distances traveled when the client is not on board the ambulance. MAA pays for loaded mileage only as follows:

     (a) MAA pays ground ambulance providers for the actual mileage incurred for covered trips by paying from the client's point of pick-up to the point of destination.

     (b) MAA pays air ambulance providers for the statute miles incurred for covered trips by paying from the client's point of pick-up to the point of destination.

     (4) MAA does not ((reimburse)) pay for ambulance services if:

     (a) The client is not transported ((to an appropriate treatment facility)); ((or))

     (b) The client is transported but not to an appropriate treatment facility; or

     (c) The client dies before the ambulance trip begins (see the single exception for ground ambulance providers at WAC 388-546-0500(2)).

     (5) For clients in the categorically needy/qualified Medicare beneficiary (CN/QMB) and medically needy/qualified Medicare beneficiary (MN/QMB) programs MAA's payment is as follows:

     (a) If Medicare covers the service, MAA will pay the lesser of:

     (i) The full coinsurance and deductible amounts due, based upon Medicaid's allowed amount; or

     (ii) MAA's maximum allowable for that service minus the amount paid by Medicare.

     (b) If Medicare does not cover or denies ambulance services that MAA covers according to this chapter, MAA pays at MAA's maximum allowable; except MAA does not pay for clients on the qualified Medicare beneficiaries (QMB) only program.

[Statutory Authority: RCW 74.08.090, 74.09.500, 74.04.050, 74.04.055, and 74.04.057. 01-03-084, § 388-546-0400, filed 1/16/01, effective 2/16/01.]

     (2) Except as provided in subsections (3) and (5) of this section, MAA does not cover hospital to hospital transfers of clients under fee-for-service when ambulance transportation is requested solely to:

     (a) Accommodate a physician's or other health care provider's preference for facilities;

     (b) Move the client closer to family or home (i.e., for personal convenience); or

     (c) Meet insurance requirements or hospital/insurance agreements.

     (3) MAA covers under fee-for-service ambulance transportation for a client being transferred from one hospital to another when the transferring or discharging hospital has inadequate facilities to provide the necessary medical services required by the client. MAA covers air ambulance transportation for hospital transfers only if transportation by ground ambulance would endanger the client's life or health. The reason for transferring a client from one hospital to another, as well as the need for air ambulance transport, if applicable, must be clearly documented in the client's hospital chart and in the ambulance trip report.

     (4) MAA does not cover under fee-for-service ambulance transportation for a client being transferred from a hospital providing a higher level of care to a hospital providing a lower level of care, except as allowed under subsection (5) of this section.

     (5) MAA considers requests for fee-for-service ambulance coverage under the provisions of WAC 388-501-0160 (exception to rule) for transportation of a client from an intervening hospital to the discharging hospital. MAA evaluates such requests based on clinical considerations and cost-effectiveness. MAA's decision under the provisions of WAC 388-501-0160 is final. The reason for transferring a client from a hospital to another medical facility must be clearly documented in the client's hospital chart and in the ambulance trip record.

     (6) Specialty care transport (SCT) is hospital-to-hospital transportation by ground ambulance of a critically injured or ill client, at a level of service beyond the scope of a paramedic. MAA pays an ambulance provider the advanced life support (ALS) rate for an SCT-level transport, provided:

     (a) The criteria for covered hospital transfers under fee-for-service are met; and

     (b) There is a written reimbursement agreement between the ambulance provider and SCT personnel. If there is no written reimbursement agreement between the ambulance provider and SCT personnel, MAA pays the provider at the basic life support (BLS) rate.

[]

     (a) A BLS ((emergency)) ambulance trip is one in which the client requires and receives basic medical services ((on-)) at the scene and/or en route from the scene of the acute and emergent illness or injury to a hospital or other appropriate treatment facility. Examples of basic medical services are: Controlling bleeding, splinting fracture(s), treating for shock, and performing cardiopulmonary resuscitation (CPR).

     (b) An ALS trip is one in which the client requires and receives more complex services ((on-)) at the scene and/or en route from the scene of the acute and emergent illness or injury to a hospital. To qualify for payment at the ALS level, certified paramedics or other ALS-qualified personnel on-board must provide the advanced medical services in a properly equipped vehicle as defined by chapter 18.83 RCW. Examples of ((more)) complex medical services or ALS procedures are: ((the initiation of intravenous therapy, airway intubation, or heart defibrillation. To qualify for reimbursement at the ALS level, certified paramedics or other ALS-qualified personnel on-board must provide the advanced medical services in a properly equipped vehicle.))

     (i) Administration of medication by intravenous push/bolus or by continuous infusion;

     (ii) Airway intubation;

     (iii) Cardiac pacing;

     (iv) Chemical restraint;

     (v) Chest decompression;

     (vi) Creation of surgical airway;

     (vii) Initiation of intravenous therapy;

     (viii) Manual defibrillation/cardioversion;

     (ix) Placement of central venous line; and

     (x) Placement of intraosseous line.

     (2) MAA ((reimburses)) pays for ambulance services (BLS or ALS) based on the client's actual medical condition and the level of medical services needed and provided during the trip.

     (a) Local ordinances or standing orders that require all ambulance ((trips)) vehicles be ALS-equipped do not qualify a trip for MAA ((reimbursement)) payment at the ALS level of service unless ALS services were provided.

     (b) A ground ambulance trip is classified and paid at a BLS level, even if certified paramedics or ALS-qualified personnel are on board the ambulance, if no ALS-type interventions were provided en route.

     (c) An ALS assessment does not qualify as an ALS transport if no ALS-type interventions were provided to the client en route to the treatment facility.

     (3) ((MAA reimburses separately for:)) MAA's base rate includes: Necessary personnel and services; oxygen and oxygen administration; ((and/or)) intravenous supplies and IV administration((. All other)) reusable supplies, disposable supplies, required equipment ((and up to thirty minutes of waiting time are included in MAA's base rate. MAA includes in the base rate equipment and/or supplies that are not specifically listed as separately payable in the medical transportation billing instructions)), and waiting time. MAA does not ((reimburse for)) pay separately for chargeable items/services that are provided to the client based on standing orders.

     (4) ((The provider must document each trip to reflect the level of care needed by the patient, the training and qualifications of the personnel on board and the types of medical interventions provided by the personnel on-board. A ground ambulance trip is classified and paid at a BLS level, even if certified paramedics or ALS-qualified personnel are on board the ambulance, if no ALS-type interventions are needed and provided en route.

     (5))) MAA ((reimburses)) pays ground ambulance providers ((one)) the same mileage ((reimbursement)) rate, regardless of the level of service. Ground ambulance mileage is ((reimbursed)) paid when the client is transported to and from medical services within the local community only, unless necessary medical care is not available locally. The provider must fully document in the client's record the circumstances that make medical care outside of the client's local community necessary.

     (5) MAA pays for extra mileage when sufficient justification is documented in the client's record and the ambulance trip report. Acceptable reasons for allowable extra mileage include, but are not limited to:

     (a) A hospital was on "divert" status and not accepting patients; or

     (b) A construction site caused a detour, or had to be avoided to save time.

     (6) When multiple ambulance providers respond to an emergency call, MAA pays only the ambulance provider that actually furnishes the transportation.

     (7) MAA ((reimburses)) pays for an extra attendant, when the ground ambulance provider ((submits)) documents in the client's file the justification ((to MAA for an)) for the extra attendant ((along with the claim for trip reimbursement)), and that the extra attendant is on-board for the trip because of one or more of the following:

     (a) The client weighs three hundred pounds or more;

     (b) The client is violent or difficult to ((control)) move safely;

     (c) The client is being transported for Involuntary Treatment Act (ITA) purposes and the client must be restrained during the trip; or

     (d) More than one client is being transported, and each requires medical attention and/or close monitoring.

     (((7) The first thirty minutes of waiting time is included in MAA's base rate. MAA reimburses ground ambulance providers for additional waiting time if the time:

     (a) Is extensive;

     (b) Constitutes unusual circumstances; and

     (c) Is documented in the provider's records and on the billing form. Documentation must include the reason for the wait, the total length of time spent waiting and the amount of waiting time being billed to MAA.

     (8) MAA does not reimburse providers for waiting time if:

     (a) The waiting time is to provide a return trip pickup; or

     (b) The waiting time is to provide a second trip for the same client for the same date of service.

     (9))) (8) MAA ((reimburses)) pays ambulance providers "by report" for ferry and bridge tolls incurred when transporting MAA clients. ((The ferry toll(s) must be thoroughly documented on the claim form. MAA reimburses:

     (a) One standard reimbursement rate for all Puget Sound ferry trips (each way); and

     (b) Actual cost, based on invoice, for all San Juan Island ferry trips.

     (10) MAA reimburses ambulance providers for bridge tolls based on actual cost. To be reimbursed, the provider must submit the receipt(s) for the bridge toll(s) incurred during the trip)) To be paid, providers must document the toll(s) by attaching the receipt(s) for the toll(s) to the claim.

[Statutory Authority: RCW 74.08.090, 74.09.500, 74.04.050, 74.04.055, and 74.04.057. 01-03-084, § 388-546-0450, filed 1/16/01, effective 2/16/01.]

     (a) At a reduced base rate for the additional client, and

     (b) No mileage charge for the additional client.

     (2) MAA ((reimburses a)) pays an ambulance provider at the appropriate base rate (((no mileage and no separate supplies if there is)) (BLS or ALS) if no transportation ((provided)) takes place because the client died ((on scene. MAA allows reimbursement only if)) at the scene of the illness or injury but the ambulance crew ((provides necessary and substantial)) provided medical ((care)) interventions/supplies to the client ((on-)) at the scene ((and)) prior to the client's death. See WAC 388-546-0450(1) for examples of medical interventions associated with each base rate. The intervention(s)/supplies provided must be documented in the client's record. No mileage charge is allowed with the base rate when the client dies at the scene of the illness or injury after medical interventions/supplies are provided but before transport takes place.

     (3) In situations where a BLS entity provides the transport of the client and an ALS entity provides a service that meets MAA's fee schedule definition of an ALS intervention, the BLS provider may bill MAA the ALS rate for the transport, provided a written reimbursement agreement between the BLS and ALS entities exists. The provider must give MAA a copy of the agreement upon request. If there is no written agreement between the BLS and ALS entities, MAA will pay only for the BLS level of service.

     (4) In areas that distinguish between residents and nonresidents, MAA must be billed the same rate for ambulance services provided to a client in a particular jurisdiction as would be billed by that provider to the general public in the same jurisdiction.

[Statutory Authority: RCW 74.08.090, 74.09.500, 74.04.050, 74.04.055, and 74.04.057. 01-03-084, § 388-546-0500, filed 1/16/01, effective 2/16/01.]

     Reviser's note: RCW 34.05.395 requires the use of underlining and deletion marks to indicate amendments to existing rules. The rule published above varies from its predecessor in certain respects not indicated by the use of these markings.
AMENDATORY SECTION(Amending WSR 01-03-084, filed 1/16/01, effective 2/16/01)

WAC 388-546-0600   Procedure code modifiers.   ((Ground)) Ambulance providers must use procedure code modifiers published by MAA when billing MAA for ((ground)) ambulance trips. The ((same)) appropriate modifiers ((that describe the ambulance trip's place of origin and the client's destination)) must be used for all services related to the same trip for the same client.

[Statutory Authority: RCW 74.08.090, 74.09.500, 74.04.050, 74.04.055, and 74.04.057. 01-03-084, § 388-546-0600, filed 1/16/01, effective 2/16/01.]

     (a) The necessary medical treatment is not available locally or the client's ((pick up)) point of pick up is not accessible by ground ambulance;

     (b) The vehicle and crew meet the provider requirements in WAC 388-546-0300 and 388-546-0800;

     (c) The client's destination is an acute care hospital; and

     (d) The client's physical/medical condition requires immediate and rapid ambulance transportation that cannot be provided by ground ambulance; or

     (e) The client's physical or medical condition is such that traveling on a commercial flight is not safe.

     (2) MAA ((reimburses)) pays providers for one lift-off fee per client, per trip.

     (3) ((MAA reimburses mileage for air ambulance services based on air miles and not on highway mileage charts)) Air mileage is based on loaded miles flown, as expressed in statute miles.

     (4) Except as provided in WAC 388-546-0800(6), MAA pays for extra air mileage with sufficient justification. The reason for the added mileage must be documented in the client's record and the ambulance trip report. Acceptable reasons include, but are not limited to:

     (a) Having to avoid a "no fly zone"; or

     (b) Being forced to land at an alternate destination due to severe weather.

     (5) MAA ((reimburses)) pays a lift-off fee for each client when two or more clients are transported on a single air ambulance trip. In such a case, the provider must divide equally the total air mileage by the number of clients transported and bill MAA for the mileage portion attributable to each eligible client.

     (((5))) (6) If a client's transportation requires use of more than one ambulance to complete the trip to the hospital or other approved facility, MAA limits its ((reimbursement)) payment as follows:

     (a) If ((more than one)) air ambulance is used and the trip involves more than one lift-off, MAA ((reimburses)) pays only one lift-off fee per client and the total of air miles. If an air ambulance transport for the same client involves both rotary and fixed wing aircraft, the lift-off fee and mileage ((reimbursement)) payment will be based on the mode of air transport used for the greater distance traveled.

     (b) If both air and ground ambulances ((must be)) are used, MAA ((reimburses)) pays one lift-off fee and total air miles to the air ambulance provider, and the applicable base rate and ground mileage to each ground ambulance provider involved in the trip((. The one exception to this rule is when the)), except when ground ambulance ((fee(s) is)) fees are included in the negotiated trip payment as provided in WAC 388-546-0800 (((4)(b))) (6).

     (((6))) (7) MAA does not ((reimburse)) pay separately for individual services or an extra attendant for air ambulance transportation. MAA's lift-off fee and mileage ((reimbursement)) payment includes all personnel, services, supplies, and equipment related to the ((trip)) transport.

     (((7))) (8) MAA does not ((reimburse)) pay private organizations for volunteer medical air ambulance transportation services, unless the organization has MAA's prior authorization for the transportation services and fees ((are prior authorized by MAA)). If authorized, MAA's ((reimbursement)) payment is based on the actual cost to provide the service or at MAA's established rates, whichever is lower. MAA does not ((reimburse)) pay separately for items or services that MAA includes in the established rate(s).

     (((8))) (9) If MAA determines, upon review, that an air ambulance trip was not:

     (a) Medically necessary, MAA may deny or recoup its payment and/or limit ((reimbursement)) payment based on MAA's established rate for a ground ambulance trip (((if that would result in a lower cost to MAA))) provided ground ambulance transportation was medically necessary; or

     (b) To the nearest available and appropriate hospital, MAA may deny or recoup its payment ((and impose a maximum reimbursement)) and/or limit its maximum payment for the trip based on the ((nearer)) nearest available and appropriate facility.

     (((9))) (10) Providers must have prior authorization from MAA for any nonemergency air transportation, whether by air ambulance or other mode of air transportation. Nonemergency air transportation includes scheduled transports to or from out-of-state treatment facilities.

     (((10))) (11) MAA uses commercial airline companies (i.e., ((limits)) MAA does not authorize air ambulance ((services)) transports) whenever the client's medical condition permits the client to be transported by nonmedical and/or scheduled carriers.

     (((11))) (12) MAA does not ((reimburse)) pay for air ambulance services if ((there is)) no transportation is provided.

[Statutory Authority: RCW 74.08.090, 74.09.500, 74.04.050, 74.04.055, and 74.04.057. 01-03-084, § 388-546-0700, filed 1/16/01, effective 2/16/01.]

     (((1))) MAA requires ((any)) out-of-state ((ground or air)) ambulance ((provider who provides)) providers who provide covered medical services to ((an)) eligible MAA ((client)) clients to:

     (a) Meet the licensing requirements of the ambulance provider's home state (United States of America and its territories only); and

     (b) Complete and sign an MAA core provider agreement.

     (2) MAA does not ((reimburse for an interstate trip if the client is eligible for in-state services, only)) pay for an out-of-state ambulance transport for a fee-for-service client when:

     (a) The client's medical eligibility program covers medical services within Washington state and/or designated bordering cities only. See WAC 388-546-0150 and 388-546-0200(5);

     (b) The ambulance transport is taking the client to an out-of-state treatment facility for a medical service, treatment or procedure that is available from a facility within Washington state or in a designated bordering city; or

     (c) The transport was nonemergent and was not prior authorized by MAA.

     (3) Except as provided in subsection (6) of this section, MAA ((reimburses)) pays out-of-state medical transportation ambulance providers at the lower of:

     (a) The provider's billed amount; or

     (b) The rate established by MAA.

     (4) MAA requires any out-of-state ground ambulance provider who is transporting MAA clients within the state of Washington to comply with RCW 18.73.180 regarding stretcher transportation.

     (5) ((Air)) Ambulance providers who provide ((emergency)) medical transportation that takes a client out-of-state or that brings a client in state from an out-of-state location must obtain MAA's prior authorization. Under no circumstances are such transports covered for clients under the Involuntary Treatment Act (ITA).

     (6) MAA ((reimburses air)) pays ambulance providers the agreed upon ((rate)) amount for each medically necessary interstate ((air)) ambulance trip that has MAA's prior authorization. The provider is responsible for ensuring that all necessary services associated with the transport are available and provided to the client. In transports involving negotiated rates, the provider is responsible for the costs of all services included in the contractual amount. The contractual amount for an air ambulance transport may include ground ambulance fees at the point of pick-up and the point of destination.

[Statutory Authority: RCW 74.08.090, 74.09.500, 74.04.050, 74.04.055, and 74.04.057. 01-03-084, § 388-546-0800, filed 1/16/01, effective 2/16/01.]

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     (a) ((The client needs to have basic ambulance level medical attention available during transportation; or

     (b))) The client is bed-confined and must be transported by stretcher or gurney (in the prone or supine position) for medical or safety reasons. Justification for stretcher or gurney must be documented in the client's record; or

     (b) The client's medical condition requires that he or she have basic ambulance level medical attention available during transportation, regardless of bed confinement.

     (2) MAA requires ambulance providers to thoroughly document the circumstances requiring nonemergency ground ambulance transportation((.)) as follows:

     (a) For nonemergency, scheduled ambulance services that are repetitive in nature, the ambulance provider must obtain a written physician certification statement (PCS) from the client's attending physician certifying that the ambulance services are medically necessary. The PCS must specify the expected duration of treatment or span of dates during which the client requires repetitive nonemergency ambulance services. The PCS must be dated no earlier than sixty days before the first date of service. A PCS for repetitive, nonemergency ambulance services is valid for sixty days as long as the client's medical condition does not improve. Kidney dialysis clients may receive nonemergency ground ambulance transportation to and from outpatient kidney dialysis services for up to three months per authorization span.

     (b) For nonemergency ambulance services that are either unscheduled or scheduled on a nonrepetitive basis, the ambulance provider must obtain from the client's attending physician a signed PCS within forty-eight hours after the transport. The PCS must certify that the ambulance services are medically necessary.

     (c) If the ambulance provider is not able to obtain a signed PCS from the attending physician, a signed certificate of medical necessity form must be obtained from a qualified provider who is employed by the client's attending physician or by the hospital or facility where the client is being treated and who has personal knowledge of the client's medical condition at the time the ambulance service was furnished. In lieu of the attending physician, one of the following may sign the certification form: a physician assistant, a nurse practitioner, a registered nurse, a clinical nurse specialist, or a hospital discharge planner. The signed certificate must be obtained from the alternate provider no later than twenty-one calendar days from the date of service.

     (d) If, after twenty-one days, the ambulance provider is unable to obtain the signed PCS from the attending physician or alternate provider for nonemergency ambulance services that are either unscheduled or scheduled on a nonrepetitive basis, the ambulance provider may submit a claim to MAA, as long as the provider is able to show acceptable documentation of the attempts to obtain the PCS.

     (e) In addition to the signed certification statement of medical necessity, all other program criteria must be met in order for MAA to pay for the service.

     (3) Ground ambulance providers may choose to enter into contracts with MAA's transportation brokers to provide nonemergency transportation at a negotiated payment rate. Any such subcontracted rate may not exceed the costs MAA would incur under subsection (1) of this section.

[Statutory Authority: RCW 74.08.090, 74.09.500, 74.04.050, 74.04.055, and 74.04.057. 01-03-084, § 388-546-1000, filed 1/16/01, effective 2/16/01.]

     (2) MAA authorizes a nonemergency air ambulance transport only when the following conditions are met:

     (a) The client's destination is an acute care hospital or approved rehabilitation facility; and

     (b) The client's physical or medical condition is such that travel by any other means endangers the client's health; or

     (c) Air ambulance is less costly than ground ambulance under the circumstances.

     (3) MAA requires providers to thoroughly document the circumstances requiring a nonemergency air ambulance transport. The medical justification must be submitted to MAA prior to transport and must be documented in the client's medical record and ambulance trip report. Documentation must include adequate descriptions of the severity and complexity of the client's condition at the time of transportation.

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     (2) For clients who are otherwise eligible for out-of-state coverage under WAC 388-546-0150, but have other third-party insurance, MAA does not pay for transportation to or from out-of-state treatment facilities when the client's primary insurance:

     (a) Denies the client's request for medical services out-of-state for lack of medical necessity; or

     (b) Denies the client's request for transportation for lack of medical necessity.

     (3) For clients who are otherwise eligible for out-of-state coverage under WAC 388-546-0150, but have other third-party insurance, MAA does not consider requests for transportation to or from out-of-state treatment facilities unless the client has tried all of the following:

     (a) Requested coverage of the benefit from his/her primary insurer and been denied;

     (b) Appealed the denial of coverage by the primary insurer; and

     (c) Exhausted his/her administrative remedies through the primary insurer.

     (4) If MAA authorizes transportation to or from an out-of-state treatment facility for a client with other third-party insurance, MAA's liability is limited to the cost of the least costly means of transportation that does not jeopardize the client's health, as determined by MAA in consultation with the client's referring physician.

     (5) For clients eligible for out-of-state coverage but have other third-party insurance, MAA considers requests for transportation to or from out-of-state treatment facilities under the provisions of WAC 388-501-0165.

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     (2) Ambulance providers may apply to the department of health (DOH) for possible grants related to transports of qualified trauma cases.

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     (a) "Nearest and most appropriate destination" means the nearest facility able and willing to accept the involuntarily detained individual for treatment, not the closest facility based solely on driving distance.

     (b) "County-designated mental health professional (CD-MHP)" means a person who, under the guidelines specified by the Involuntary Treatment Act (ITA):

     (i) Assesses a client's level of need for transportation according to procedures established by the county in which the client being assessed resides; and

     (ii) Decides, following the assessment, how a client should be transported to an inpatient psychiatric treatment facility.

     (c) "Involuntary Treatment Act" means, for adults, chapter 71.05 RCW; for juveniles, chapter 71.34 RCW. See also chapter 388-865 WAC.

     (d) "Regional support network (RSN)" means a county authority or group of county authorities recognized by the secretary of the department of social and health services (DSHS) and which contracts with DSHS to implement a locally managed community mental health program.

     (2) The medical assistance administration (MAA) covers transportation under ITA for an individual who is being involuntarily detained for mental health treatment, after that individual has been assessed by a CD-MHP and found to be:

     (a) A danger to self;

     (b) A danger to others; or

     (c) Gravely disabled.

     (3) Transportation under ITA may be provided to an eligible individual by an organization designated as an ITA provider by the local community mental health center and/or RSN. Designated ITA providers must comply with the department's requirements for drivers, driver training, vehicle and equipment standards and maintenance.

     (4) Transportation under the ITA for an individual described in subsection (2) is covered from:

     (a) The site of the initial detention;

     (b) An evaluation and treatment facility designated by the department; or

     (c) A court hearing.

     (5) Transportation under the ITA for an individual described in subsection (2) is covered when provided to:

     (a) An evaluation and treatment facility;

     (b) A less restrictive alternative setting, except when ambulance transport to a client's home is not covered; or

     (c) A court hearing.

     (6) The CD-MHP authorizes the level of transportation provided under ITA to and from covered facilities based on the individual's need. A copy of the authorization by the CD-MHP must be kept in the individual's file.

     (7) MAA pays for ITA transports to the nearest and most appropriate destination. The reason for the diversion to a more distant facility must be clearly documented in the individual's file.

     (8) The department's mental health division (MHD) establishes payment for ITA transports. Providers must clearly identify ITA transports on the claim form when submitting claims to MAA.

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