Date of Adoption: January 16, 2001.

Purpose: The department has consolidated and clarified rules regarding ambulance transportation services in a new chapter. The proposed rules reflect long-standing department policy, are more readable, and comply with the Governor's Executive Order 97-02 on regulatory reform.

New Transportation program -- Ambulance services, 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.

Citation of Existing Rules Affected by this Order: Repealing WAC 388-86-086 and 388-87-036.

Statutory Authority for Adoption: RCW 74.08.090 and 74.09.500.

Other Authority: RCW 74.04.050, 74.04.055, and 74.04.057.

Adopted under notice filed as WSR 00-17-125 on August 18, 2000.

Changes Other than Editing from Proposed to Adopted Version: Changes to the proposed rule text for chapter 388-546 WAC are detailed below.

WAC 388-546-0200 Scope of coverage for ground and air ambulance.

(1) All ambulance transportation to and from medical services covered under the client's medical assistance program must be:

(a) Medically necessary based on the client's condition at the time of the ambulance trip;

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

(c) To the closest available MAA contracted medical provider of MAA covered services; and

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

(d) To one of the following destinations:

(i) The closest 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 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.

(3) If Medicare or another third party is the client's primary health insurer and that primary party denies coverage of an ambulance trip due to a lack of medical necessity, MAA relies on requires the provider to report: (a) t That third party determination on the billing to MAA; and (b) A justification for that the trip does not showing that the trip meets the medical necessity criteria of MAA.

WAC 388-546-0250 Ambulance services that MAA does not cover.

(1) MAA evaluates a request for any service that is listed as noncovered in this section under the provisions of WAC 388-501-0165.

(2) 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.

(3) 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;

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

(d) For a client who dies after the ambulance arrives on-scene but prior to transport and the ambulance crew did not provide any significant medical services on-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 the necessary medical service to the client's location;

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

(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).

(2)(4) MAA does not cover ambulance services for hospital to hospital transportation...

WAC 388-546-0450 Ground ambulance levels of service and other reimbursement.

(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. as determined by MAA;

(b) Constitutes unusual circumstances. as determined by MAA; and

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

WAC 388-546-0500 Special circumstances and payment limits for ground ambulance services.

(2) MAA may reimburses a provider at the appropriate base-_rate (no mileage an no separate supplies) if there is no transportation provided...

WAC 388-546-0700 Specific payment limitations for air ambulance services.

(5) 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 as follows:

(a) If more than one air ambulance...

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

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

WAC 388-546-0800 Payment for ground and air ambulance services outside the state of Washington.

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

(a) Meet the licensing requirements of the ambulance provider's home state...; and

(b) Be participating in the Medicaid program of the ambulance provider's home state; and

(c) 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.

(3) MAA reimburses out-of-state 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.

(3)(5) Air ambulance providers who provide emergency 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.

(4)(6) MAA reimburses air ambulance providers the agreed upon rate for each medically necessary interstate air ambulance trip:...

(5) MAA does not reimburse for an interstate rip if the client is eligible for in-state services only.

(6) MAA reimburse out of state providers at the lower of:

(a) The provider's billed amount; or

(b) The rate established by MAA.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, 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 13, Amended 0, Repealed 2.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 13, Amended 0, Repealed 2.

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 13, Amended 0, Repealed 2. Effective Date of Rule: Thirty-one days after filing.

January 16, 2001

Charles Hunter, Director

Administrative Services Division

Reviser's note: The material contained in this filing exceeded the page-count limitations of WAC 1-21-040 for appearance in this issue of the Register. It will appear in the 01-04 issue of the Register.

Washington State Code Reviser's Office