(1) The medicaid agency pays for a nonemergency air ambulance transport only when the transport is prior authorized by the agency.

(2) The agency 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) The agency requires providers to thoroughly document the circumstances requiring a nonemergency air ambulance transport. The medical necessity justification and all supporting documentation must be received, evaluated, and approved by the agency before the air ambulance transport takes place.

(4) The agency pays a negotiated rate for a medically necessary nonemergency interstate air ambulance transportation that the agency has prior authorized. The air ambulance provider is responsible for ensuring that all medical services necessary for the client's health and safety during the transport are available on board the vehicle or aircraft.

(5) Unless otherwise specified in the agency's authorization letter, the contractual amount for a nonemergency air ambulance transport includes:

(a) The cost of medically necessary ground transportation from the discharge facility to the point-of-pickup (airstrip); and

(b) The cost of medically necessary ground ambulance transportation from the landing point (airstrip) to the receiving facility.

(6) Payment for nonemergency air ambulance transportation clients may not exceed published fee schedule amounts, except when the agency expressly allows payment of a negotiated rate for a prior authorized nonemergency transport.

(7) Billing documentation must include a copy of the agency's authorization letter, adequate descriptions of the severity and complexity of the transport, and the medical interventions provided in transit.