PDFWAC 182-546-0200

Ambulance transportation—Scope of coverage.

(1) The ambulance program is a medical transportation service. The medicaid agency pays for ambulance transportation to and from covered medical services when the transportation is:
(a) Within the scope of an eligible client's medical care program (see WAC 182-501-0060);
(b) Medically necessary as defined in WAC 182-500-0070 based on the client's condition at the time of the ambulance trip and as documented in the client's record;
(c) Appropriate to the client's actual medical need; and
(d) To one of the following destinations:
(i) The closest and most appropriate agency-contracted medical provider of agency-covered services; or
(ii) The designated trauma facility as identified in the emergency medical services and trauma regional patient care procedures manual.
(2) The agency limits coverage to 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 agency does not cover the ambulance service. See WAC 182-546-0250 (1) and (2) for noncovered ambulance services.
(3) If medicare or another third party is the client's primary health insurer and that primary insurer denies coverage of an ambulance trip due to a lack of medical necessity, the agency requires the provider when billing the agency for that trip to:
(a) Attach the third-party determination to the claim; and
(b) Submit documentation showing that the trip meets the agency's medical necessity criteria. See WAC 182-546-1000 and 182-546-1500 for requirements for nonemergency ambulance coverage.
(4) The agency covers the following ambulance transportation:
(a) 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 the agency determines that air ambulance is less costly than ground ambulance in a particular case. In the latter case, the agency must prior authorize the air ambulance transportation. See WAC 182-546-1500 for nonemergency air ambulance coverage.
(5) See also WAC 182-531-1740 Treat and refer services.
[Statutory Authority: RCW 41.05.021, 41.05.160, 2015 c 157, 2017 c 273, and 2016 1st sp.s. c 29. WSR 20-17-010, § 182-546-0200, filed 8/6/20, effective 9/6/20. Statutory Authority: RCW 41.05.021, 41.05.160, and 2017 c 273. WSR 19-19-090, § 182-546-0200, filed 9/18/19, effective 10/19/19. WSR 11-14-075, recodified as § 182-546-0200, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.08.090, 74.09.530, and 74.09.700. WSR 06-24-036, § 388-546-0200, filed 11/30/06, effective 1/1/07. Statutory Authority: RCW 74.04.057, 74.08.090, and 74.09.510. WSR 04-17-118, § 388-546-0200, filed 8/17/04, effective 9/17/04. Statutory Authority: RCW 74.08.090, 74.09.500, 74.04.050, 74.04.055, and 74.04.057. WSR 01-03-084, § 388-546-0200, filed 1/16/01, effective 2/16/01.]