CSHCN 2009 > Ambulance > Emergency Air Ambulance Transportation

9.3.2 Claims Information

Ambulance claims must be submitted to TMHP in an approved electronic format or on the CMS-1500 claim form. Providers may purchase CMS-1500 claim forms from the vendor of their choice. TMHP does not supply the forms.

When completing a CMS-1500 claim form, all required information must be included on the claim, as information is not keyed from attachments. Superbills, or itemized statements, are not accepted as claim supplements.

Emergency ambulance claims must include the appropriate ICD-9-CM diagnosis code in Block 21 of the CMS-1500 claim form or electronic equivalent.

Providers billing electronically can enter the data supporting the necessity for the emergency transport in the Comments field or the Purpose of Stretcher field of the electronic claim. Providers using the
CMS-1500 paper claim form can enter relevant vital signs and detailed narrative in Block 19 or 21 of the claim form. For ambulance transfers where the destination is a hospital, enter the name and address of the facility in Block 32.

Run sheets, medical records, or emergency room records are not required to be submitted with the claim submission. If, however, documentation is submitted with the claim, an emergency medical technician's signature is required on all of the documents.

Note: Providers must maintain any documentation that substantiates the medical need for the transport and must ensure that the documentation is available to the CSHCN Services Program or its designee upon request.

Refer to: Chapter 36, "TMHP Electronic Data Interchange (EDI)" for information on electronic claims submissions.

Chapter 5, "Claims Filing, Third-Party Resources, and Reimbursement" for general information about claims.

Section 5.7.1.3, "CMS-1500 Claim Form Instructions" for instructions on completing paper claims. Blocks that are not referenced are not required for processing by TMHP and may be left blank.