Ambulance & medical transportation

These services may or may not be covered by all CoOportunity Health plans. Please see your plan documents for your own coverage information. If there is a difference between this general information and your plan documents, your plan will be used to determine your coverage.

Administrative process

• Fixed Wing Air Ambulance for hospital to hospital transfers, including air transportation to return to the network requires prior authorization from the Disease & Case Management Department.
• All other transportation services do not require prior authorization.

Note:

• To request prior authorization for air ambulance services or transportation to return to the service area, please call 1-800-255-1886 (ext. 36277). Voicemail is available 24 hours per day/7 days per week.
• If you are calling Monday-Friday, 8:00am to 5:00pm CST (excluding national holidays), you may call the above number and press 0# to speak with Case Management staff.
• If the situation is urgent and it is outside regular business hours as above, call the CareLine at 1-800-551-0859.

Ambulance and medical transportation is covered for medical emergencies per the indications listed below, and per your plan documents.

Service must be provided by a contracted vendor for in-network benefits to apply.

Indications that are covered

1. Emergent situations as defined below
2. Medical emergency situations as defined below
3. Transfers between hospitals for treatment by network physicians are covered, if initiated by a network physician.
4. Transfers from a hospital or at home to other facilities are covered, if medical supervision is required en route.
5. Emergency Air Transportation (helicopter): Emergency transportation by air ambulance is covered if the member has a potentially life-threatening condition that does not permit the member to use another form of transportation. Out of Area emergency admission transportation is covered when the member needs primary or secondary transportation to the nearest facility qualified to treat the medical emergency.
6. OOA (Out of Area) emergency admission transportation is covered when the member needs primary or secondary transportation to the nearest facility qualified to treat the medical emergency.
7. Medically necessary emergency medical care provided by an ambulance service when the member is not transported to a hospital.
8. Care provided by first responders. Examples include, but are not limited to, a rural area where the fire department arrives first and stabilizes the patient’s condition. The patient may then be taken to the ER by a family member or an ambulance once the patient is stable enough for transport. The care given by the fire department is covered.

Indications that are not covered

1. Transportation for non-emergent situations.
2. Transfers from home or a covered SNF (skilled nursing facility) to a physician’s office or other facilities for outpatient treatment, procedures or tests.
3. Transportation which does not require medical supervision en route.

Advanced Life support Transport (ALS): An Emergency Medical system (EMS) that has the organization, equipment and trained personnel to provide interventive medical care under medical control up to and beyond the basic life support level.

Ambulatory: Member is able to walk to a vehicle for transport.

Basic Life Support Transport (BLS): An Emergency Medical system (EMS) that has the organization, equipment and trained personnel to ensure that life threatening situations and potentially serious injuries can be reported and recognized. Have the ability to reduce the seriousness of an emergency situation and transport patients to appropriate facilities for treatment.

Emergent: Member requires some form of medical supervision (ALS, BLS).

Medical Emergency:

• The sudden, unexpected onset of illness or injury which, if left untreated or unattended until the next available primary care clinic hours, would result in hospitalization
• A condition requiring professional health services immediately to preserve life or stabilize health.
• Requires life support rescue unit intervention (ALS, BLS).

Medical Supervision: Medical personnel required to manage IV therapy, ventilator, suction, etc., to provide treatment.

Non-ambulatory: Member cannot walk to vehicle.

Non-emergent transport: Member’s condition is not life threatening and does not require medical supervision. This is usually used for visits to and from a medical facility.

First responder is a term applied to the fist individual who arrives at the scene or an emergency. The first responder uses a limited amount of equipment to perform initial assessment and intervention and is trained to assist other emergency medical services providers.

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

 

This information is for most, but not all, CoOportunity Health plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

CoOportunity Health has contracted with HealthPartners Administrators, Inc. to provide claims processing, medical management and certain other administrative services.