Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    QualChoice covers Medically Necessary licensed ambulance transportation services according to the terms listed in your Benefit Summary and your EOC/COC.

2)    No prior authorization will be required for emergency, urgent, or non-urgent ground or air ambulance services. All claims are subject to a medical necessity review.

3)    Ground transportation is generally the preferred method.  All air ambulance services are reviewed for Medical Necessity, and coverage will not be provided if it is determined that ground transportation was appropriate.

4)    Transfer from one facility to another.

a)    Ambulance transportation from one facility to another for the reasons specified in your EOC/COC is covered when coordinated prior to the transfer through the QualChoice Care Management department. 

b)    Use of air ambulance for inter-facility transfer in an emergency situation is covered.

c)    Use of air ambulance in a non-emergency situation will not be covered if medical necessity is not met.

5)    Air ambulance transportation may be necessary for patients with major trauma, if reduction in transport time is likely to make a difference in outcome AND if transportation by air (including the increase in time to dispatch, load, and unload) will significantly reduce total transport time. Air ambulance transport for distances less than10 miles will not be covered unless there are well documented extenuating circumstances that preclude ground transportation.

6)    Air transportation benefits must be weighed against the risks of air travel, including risk of crash, risk to medical personnel, risks related to air pressure changes, and increased difficulty of performing certain medical maneuvers in flight.

7)    Air transportation will not be covered when the time of transportation is unlikely to influence the patient’s outcome, such as patients with trauma that is not life- or limb-threatening, patients with stroke who will not arrive at a stroke center in less than three hours from the start of symptoms, or patients with symptoms of stroke that are improving.

I.     It is the policy of health plans affiliated with Centene Corporation® that air ambulance (fixed wing or rotary wing) transportation is medically necessary when all the following criteria are met:

A.   Transport by either basic or advanced life support ground ambulance would endanger the health or threaten survival of the member/enrollee. Some examples of applicable conditions include, but are not limited to:

1.    Intracranial bleeding requiring neurosurgical intervention;

2.    Cardiogenic shock;

3.    Burns requiring treatment in a burn center;

4.    Conditions requiring treatment in a Hyperbaric Oxygen Unit;

5.    Multiple severe injuries;

6.    Life-threatening trauma;

B.   The location of the member/enrollee needing transport meets any of the following:

1.    The point of pickup is inaccessible by ground vehicle (this condition could be met in Hawaii, Alaska, and in other remote or sparsely populated areas of the continental United States);

2.    Great distances or other obstacles, including traffic, or travel time exceeding 30 to 60 minutes, are involved in getting the patient to the nearest hospital with appropriate facilities via ground transportation (examples: burn care, cardiac care, trauma care, critical care, etc.);

C.   If transport is requested from one facility to the other, the transferring facility does not have the appropriate services and physician specialists to provide the necessary medical care (e.g., trauma unit, burn unit, cardiac care unit, or pediatric specialty services).

II.    It is the policy of health plans affiliated with Centene Corporation that air ambulance transportation is not medically necessary for any of the following:

A.   Member/enrollee is legally pronounced dead before the ambulance is called;

B.   Transportation is provided primarily for the convenience of the member/enrollee, member’s/enrollee’s family, or the physician;

C.   Transportation to a facility that is not an acute care hospital, such as a nursing facility, physician’s office, or home;

D.   Transportation to receive a service considered not medically necessary, even if the destination is an appropriate facility.

Limits on the annual number of trips or the cost per trip are defined in the Benefit Summary.