(1) The medicaid agency pays for air ambulance transportation for clients only when all of the following conditions are met:

(a) The client's medical condition requires immediate and rapid transportation beyond what ground ambulance can provide;

(b) The client's destination is an acute care hospital or appropriate trauma designated facility; and

(2) Other factors the agency may consider in payment decisions for air ambulance include:

(a) The point-of-pickup is not accessible by ground ambulance (e.g., mountain rescue);

(b) The necessary medical care is not available locally and time is of the essence; and

(3) Lift-off fee. The agency pays a lift-off fee for each client being transported by air ambulance to an acute care facility for medical treatment.

(a) When more than one client is transported in the same ambulance at the same time, each client must meet medical necessity criteria for the provider to receive a lift-off fee for each client transported.

(b) The agency does not pay a lift-off fee:

(i) For a client onboard an air ambulance when the client is not being transported for medical treatment (e.g., a mother accompanying a child to the hospital).

(ii) When the air ambulance is dispatched in response to a call but the client is not transported by the aircraft.

(4) Statute miles. The agency pays an air ambulance provider for statute miles incurred for covered trips by paying from the client's point-of-pickup to the point of destination.

(a) When more than one client requiring medical treatment is transported in the same air ambulance at the same time, the ambulance provider must divide the statute miles traveled by the number of clients being transported for medical treatment and bill the agency the mileage portion attributable to each client.

(b) The agency does not pay for mileage for a client who is traveling in an air ambulance but is not being transported for medical treatment (e.g., a mother accompanying a child to the hospital). Only the statute miles directly associated with the client transported for treatment may be billed to the agency.

(5) Extra mileage. The agency does not pay for extra mileage incurred during an air ambulance transport, except in an unusual circumstance. The unusual circumstance must be clearly described and documented in the ambulance trip report and the client's file. The exception for an unusual circumstance does not apply to nonemergency air transports that are prior authorized by the agency. Unusual circumstances for incurring additional air miles include, but are not limited to:

(a) Having to avoid a no fly zone;

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

(6) Lift-off fee plus mileage. The agency's payment for an air ambulance transport (lift-off fee plus mileage) includes all necessary personnel, services, supplies, and equipment. The agency does not make separate payment to air ambulance providers for unbundled services (e.g., pediatric ventilators).

(7) More than one travel segment. When an ambulance transport requires more than one travel segment (leg) to complete, the agency limits its payment for the transport as follows:

(a) If a fixed-wing aircraft is used and the transport involves more than one lift-off for the same client on the same trip (e.g., transportation from Spokane to Portland, but the aircraft makes a stop in the Tri-Cities), the agency pays the air ambulance provider for one lift-off fee for the client and the total air miles.

(b) For nonemergency air ambulance transports that are prior authorized by the agency, the negotiated rate includes both air and ground ambulance services, unless the agency's authorization letter specifically allows for ground ambulance services to be billed separately.

(8) Nonemergency air transportation – Prior authorization and negotiated rate. Nonemergency air ambulance transportation must be prior authorized by the agency.

(a) Nonemergency air ambulance transportation includes scheduled transports to or from out-of-state treatment facilities (see WAC 182-546-1500).

(b) Nonemergency air ambulance transportation that is prior authorized by the agency are paid a negotiated rate. The negotiated rate is an all-inclusive rate and may include transportation for a legally responsible family member or legal guardian accompanying the client being transported for medical treatment.

(9) The agency does not pay:

(a) For food, lodging, and other expenses of air ambulance personnel when a scheduled transport is delayed because of changes in the medical status of the client to be transported, weather conditions, or other factors;

(b) For fuel, maintenance and other aircraft-related expenses resulting from transportation delays because of changes in the medical status of the client to be transported, weather conditions, or other factors;

(c) Separately for ground ambulance services to and from airports and treatment facilities when these transportation services are specifically included in the negotiated air ambulance rate; and

(d) For canceled air ambulance transports, for any reason.

(10) The agency does not pay private organizations for volunteer medical air ambulance transportation services unless no other air ambulance option is available. The use of private, volunteer air transportation must be prior authorized by the agency to be payable. If authorized by the agency, the agency's payment for the transport is the lesser of:

(a) The provider's actual incurred and documented cost (e.g., fuel); or

(b) The agency's established rate (fee schedule).

(11) If the agency determines, upon review, that an air ambulance transport was not:

(a) Medically necessary, the agency may deny, recoup, or limit its payment to the amount the agency would have paid to a ground ambulance provider for the same distance traveled; or

(b) To the closest, most appropriate agency-contracted hospital, the agency may deny, recoup, or limit its payment to the maximum amount it would have paid an air ambulance provider for a transport to the nearest, most appropriate agency-contracted facility.

(12) The agency uses commercial airline companies whenever the client's medical condition permits the client to be transported safely by nonmedical or scheduled carriers.

PDFWAC 182-546-0700

Ambulance transportation—Air ambulance—Payment.