PDFWAC 182-546-0400

General limitations on payment for ambulance services.

(1) In accordance with WAC 182-502-0100(8), the agency pays providers the lesser of the provider's usual and customary charges or the maximum allowable rate established by the agency. The agency's fee schedule payment for ambulance services includes a base rate or lift-off fee plus mileage.
(2) The agency:
(a) Pays providers under fee-for-service for ground ambulance services provided to a client who is enrolled in an agency-contracted managed care organization (MCO).
(b) Pays providers under fee-for-service for air ambulance services provided to a client who is enrolled in an agency-contracted MCO.
(3) The agency does not pay providers for mileage incurred traveling to the point of pickup or any other distances traveled when the client is not on board the ambulance. The agency pays for loaded mileage only as follows:
(a) The agency pays ground ambulance providers for the actual mileage incurred for covered trips by paying from the client's point of pickup to the point of destination.
(b) The agency pays air ambulance providers for the statute miles incurred for covered trips by paying from the client's point of pickup to the point of destination.
(4) The agency does not pay for ambulance services if:
(a) The client is not transported, unless the services are provided under WAC 182-531-1740 Treat and refer services;
(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 182-546-0500(2)).
(5) For clients in the categorically needy/qualified medicare beneficiary (CN/QMB) and medically needy/qualified medicare beneficiary (MN/QMB) programs, the agency's payment is as follows:
(a) If medicare covers the service, the agency pays the lesser of:
(i) The full coinsurance and deductible amounts due, based upon medicaid's allowed amount; or
(ii) The agency's maximum allowable for that service minus the amount paid by medicare.
(b) If medicare does not cover or denies ambulance services that the agency covers according to this chapter, the agency pays its maximum allowable fee; except the agency does not pay for clients on the qualified medicare beneficiaries (QMB) only program.
[Statutory Authority: RCW 41.05.021, 41.05.160, and 2017 c 273. WSR 19-19-090, § 182-546-0400, filed 9/18/19, effective 10/19/19. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 18-12-091, § 182-546-0400, filed 6/5/18, effective 7/6/18. Statutory Authority: RCW 41.05.021. WSR 13-16-006, § 182-546-0400, filed 7/25/13, effective 8/25/13. WSR 11-14-075, recodified as § 182-546-0400, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.057, 74.08.090, and 74.09.510. WSR 04-17-118, § 388-546-0400, 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, § 388-546-0400, filed 1/16/01, effective 2/16/01.]