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PDFWAC 182-546-0425

Ambulance coverage during inpatient hospitals stays.

(1) The medical assistance administration (MAA) does not cover ambulance transportation services under fee-for-service when a client remains as an inpatient client in a hospital and the transportation to and/or from another facility is for diagnostic or treatment services (e.g., MRI scanning, kidney dialysis). Transportation of an inpatient client for such services is the responsibility of the hospital, whether MAA pays the hospital under the diagnosis-related group (DRG) or ratio of costs-to-charges (RCC) method.
(2) Except as provided in subsections (3) and (5) of this section, MAA does not cover hospital to hospital transfers of clients under fee-for-service when ambulance transportation is requested solely to:
(a) Accommodate a physician's or other health care provider's preference for facilities;
(b) Move the client closer to family or home (i.e., for personal convenience); or
(c) Meet insurance requirements or hospital/insurance agreements.
(3) MAA covers under fee-for-service ambulance transportation for a client being transferred from one hospital to another when the transferring or discharging hospital has inadequate facilities to provide the necessary medical services required by the client. MAA covers air ambulance transportation for hospital transfers only if transportation by ground ambulance would endanger the client's life or health. The reason for transferring a client from one hospital to another, as well as the need for air ambulance transport, if applicable, must be clearly documented in the client's hospital chart and in the ambulance trip report.
(4) MAA does not cover under fee-for-service ambulance transportation for a client being transferred from a hospital providing a higher level of care to a hospital providing a lower level of care, except as allowed under subsection (5) of this section.
(5) MAA considers requests for fee-for-service ambulance coverage under the provisions of WAC 388-501-0160 (exception to rule) for transportation of a client from an intervening hospital to the discharging hospital. MAA evaluates such requests based on clinical considerations and cost-effectiveness. MAA's decision under the provisions of WAC 388-501-0160 is final. The reason for transferring a client from a hospital to another medical facility must be clearly documented in the client's hospital chart and in the ambulance trip record.
(6) Specialty care transport (SCT) is hospital-to-hospital transportation by ground ambulance of a critically injured or ill client, at a level of service beyond the scope of a paramedic. MAA pays an ambulance provider the advanced life support (ALS) rate for an SCT-level transport, provided:
(a) The criteria for covered hospital transfers under fee-for-service are met; and
(b) There is a written reimbursement agreement between the ambulance provider and SCT personnel. If there is no written reimbursement agreement between the ambulance provider and SCT personnel, MAA pays the provider at the basic life support (BLS) rate.
[WSR 11-14-075, recodified as § 182-546-0425, 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, § 388-546-0425, filed 8/17/04, effective 9/17/04.]
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