Medical necessity is established when the patient's condition is such that use of any other method of transportation is contraindicated. In any case in which some means of transportation other than an ambulance could be used without endangering the individual's health, whether or not such other transportation is actually available, no payment may be made for ambulance services. In all cases, the appropriate documentation must be kept on file and, upon request, presented to the carrier/intermediary. It is important to note that the presence (or absence) of a physician’s order for a transport by ambulance does not necessarily prove (or disprove) whether the transport was medically necessary. The ambulance service must meet all program coverage criteria in order for payment to be made.

An ambulance transport is covered to the nearest appropriate facility to obtain necessary diagnostic and/or therapeutic services (such as a CT scan or cobalt therapy) as well as the return transport. In addition to all other coverage requirements, this transport situation is covered only to the extent of the payment that would be made for bringing the service to the patient. Medicare covers ambulance transports (that meet all other program requirements for coverage) only to the following destinations: Hospital;Critical Access Hospital (CAH);Skilled Nursing Facility (SNF);Beneficiary’s home;Dialysis facility for ESRD patient who requires dialysis; orA physician’s office is not a covered destination.

In an effort to mitigate fraud and abuse, Medicare has increased its enforcement effort on Ambulance Providers. The effort comes in the form of signature verification. The verification of authorized signers applies to Transport Order Forms/Physician Certification Statements (PCS). An authorized signer is a Physician, Physician Assistant, Nurse Practitioner, Nurse, or Discharge Planner who has personal knowledge of the medical condition of the patient being transported. For more information, download our Signature Verification Flyer here.