CSHCN 2008 > Ambulance > Claims Information

9.5 Claims Information

Emergency ambulance claims must include the appropriate ICD-9-CM diagnosis code in Block 21 of the CMS-1500 claim form or electronic equivalent. Emergency ambulance claims submitted without the ICD-9-CM diagnosis code are denied. If the diagnosis is not known at the time of transport, providers must code based on the physical signs and symptoms of the client. For all ambulance claims, providers also must submit the following additional information with the claim for reimbursement consideration:

•Distance of transport.

•Time of transport.

•Acuity of client, origin or destination modifier, and relevant vital signs.

Claims for ambulance services must include the number of loaded miles traveled for more than the base rate to be paid. If mileage (procedure code 9-A0425) is not indicated on the claim, only the base rate (procedure code 9-A0429) may be reimbursed.

For emergency and nonemergency claims, providers must enter data to support the necessity for the transport on the claim form. Providers billing electronically can use the Comments field and the Purpose of Stretcher field to enter data to support the necessity for an emergency or nonemergency transport. For providers billing on paper, relevant vital signs and narrative must be documented in Block 19 or 21 of the CMS-1500. When documenting the narrative, provide a detailed description. For nonemergency transports, the degree of disability or the client's current medical condition requiring the transport must be indicated clearly on the claim. An emergency medical technician's signature is required on all documentation submitted for the claim. Run sheets, medical records, or emergency room records are not required to be submitted with the claim submission. Although run sheets are not required for submission of claims, providers must ensure that any documentation that substantiates the medical need for the transport is available to the CSHCN Services Program or its designee upon request.

Providers must submit one of the following modifiers to indicate the origin and destination of the transport.

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.

Refer to: Chapter 33, "TMHP Electronic Data Interchange (EDI)" on page 33-1, for information on electronic claims submissions.

Chapter 5, "Reimbursement and Claims Filing" on page 5-1, for general information about claims filing.

Chapter 5, "CMS-1500 Claim Form Instructions"on page 5-19, for instructions on completing paper claims. Blocks that are not referenced are not required for processing by TMHP and may be left blank.