C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-5, subsec. 144-101-II-5.04

Current through 2024-51, December 18, 2024

Subsection 144-101-II-5.04 - COVERED SERVICES

A covered service is a service for which payment to a provider is permitted under this Section of the MaineCare Benefits Manual (MBM). The types of ambulance services that are covered for eligible individuals are subject to medical necessity and those which meet the following criteria:

5.04-1Transportation to the hospital or medical care facility which:

1. Has an available bed or outpatient service and;

2. Has the equipment and personnel to provide the required services.

5.04-2 Transportation from and to the points listed below:

ORIGIN	DESTINATION
Member's Residence	Nursing Facility (including Intermediate Care Facilities for Individuals with Intellectual Disabilities(ICF-IID))
Scene of Accident or Illness	Hospital
Scene of Accident or Illness	Nursing Facility (inc. ICF-IID)
Nursing Facility (inc. ICF-IID)	Hospital
Nursing Facility (inc. ICF-IID)	Nursing Facility (inc. ICF-IID)
Nursing Facility (inc. ICF-IID)	Member's Residence
Hospital	Nursing Facility (inc. ICF-IID)
Hospital	Hospital
Hospital	Member's Residence

When moving between two facilities having the same level of care, social/familial and medical factors must justify the move, and the move must be in accordance with the relevant provisions of the MaineCare Benefits Manual (MBM).

5.04-3Emergency medical services may be provided at the scene of an illness, injury or accident when transporting the member is not medically necessary. Examples include, but are not limited to:

(1) A member is pronounced dead after the ambulance wasdispatched to the scene;

(2) An ambulance service that provides treatment at the scene of an accident but does not transport the MaineCare member. Each emergency service that responds to the scene to provide medical treatment may be reimbursed for one A0998 Base Rate only.No mileage is billable as no loaded miles occur.

5.04-4Waiting Time is the period of time when a physician deems it medically necessary for the ambulance provider to wait at a hospital while the member is being stabilized, with the intent of continuing transport to a more appropriate hospital for care or back to the point of origin.The maximum number of hours allowed for waiting time is four hours and is billable in 30-minute increments beginning with completion of the second half-hour of waiting time.

5.04-5Out-of-State Ambulance Services

Out of state ambulance providers and any provider transporting to a location out-of-state must submit a prior authorization request through the MaineCare Portal at https://mainecare.maine.gov. Non-emergency transports must be prior authorized before the service is performed.In emergency transport cases, prior authorization may be granted retroactively.All guidelines set forth in Chapter I,Section 1.14-2 of the MaineCare Benefits Manual must be followed.

C.M.R. 10, 144, ch. 101, ch. II, 144-101-II-5, subsec. 144-101-II-5.04