C.M.R. 10, 144, ch. 101, ch. III, 144-101-III-5, subsec. 144-101-III-5.06
PROC. CODE | DESCRIPTION | MAXIMUM ALLOWANCE EFFECTIVE 3/1/15-12/31/19 | MAXIMUM ALLOWANCE EFFECTIVE 1/1/2020 | PRIOR AUTH. | REQUIRES MODIFIER | |
A0021 | AMBULANCE SERVICE; OUT OF STATE; PER MILE TRANSPORT [Out-of-state ambulance providers bill this code.] | $2.00 | $2.00 | YES | ||
A0225 | AMBULANCE SERVICE; SPECIALIZED NEONATAL TRANSPORT, BASE RATE EMERGENCY ONE WAY [GROUND][Birth to 2 years of age] (SEE NOTE E) | $300.00 | 100% of current published Medicare rate *** | |||
A0420 | AMBULANCE WAITING TIME (ALS OR BLS), ONE HALF (1/2) HOUR INCREMENTS[starting with the second completed half hour at one half hour per unit] | $95.00 | $95.00 | |||
A0424 | EXTRA AMBULANCE ATTENDANT, ALS OR BLS (REQUIRES MEDICAL REVIEW) | $32.00 | $32.00 | YES | ||
A0425 | GROUND MILEAGE, PER STATUTE MILE | 65% of current published Medicare rate* | 100% of current published Medicare rate*** | |||
A0425 | GROUND MILEAGE, PER STATUTE MILE-INVOLUNTARY ADMISSION TO A PSYCHIATRIC FACILITY | $8.00 | $8.00 | YES | ||
SEE NOTE D | ||||||
A0426 | AMBULANCE SERVICE, ADVANCED LIFE SUPPORT, NON-EMERGENCY TRANSPORT, LEVEL 1 [ALS 1] | 65% of current published Medicare rate* | 100% of current published Medicare rate*** | |||
A0427 | AMBULANCE SERVICE, ADVANCED LIFE SUPPORT, EMERGENCY TRANSPORT, LEVEL 1 [ALS 1-EMERGENCY] | 65% of current published Medicare rate* | 100% of current published Medicare rate*** | |||
A0428 | AMBULANCE SERVICE, BASIC LIFE SUPPORT, NON-EMERGENCY TRANSPORT, [BLS] | 65% of current published Medicare rate* | 100% of current published Medicare rate*** | |||
A0428 | AMBULANCE SERVICE, BASIC LIFE SUPPORT, NON-EMERGENCY TRANSPORT, [BLS]-INVOLUNTARY ADMISSION TO A PSYCHIATRIC FACILITY | $285.00 | $285.00 | YES | ||
SEE NOTE D | ||||||
A0429 | AMBULANCE SERVICE, BASIC LIFE SUPPORT, EMERGENCY TRANSPORT [BLS-EMERGENCY] | 65% of current published Medicare rate* | 100% of current published Medicare rate*** | |||
A0430 | AMBULANCE SERVICE, CONVENTIONAL AIR SERVICES, TRANSPORT, ONE-WAY [FIXED WING] (SEE NOTE B) | 65% of current published Medicare rate* | 100% of current published Medicare rate*** | ** | ||
A0431 | AMBULANCE SERVICE, CONVENTIONAL AIR SERVICES, TRANSPORT, ONE-WAY [ROTARY WING] (SEE NOTE C) | 65% of current published Medicare rate* | 100% of current published Medicare rate*** | ** | ||
A0433 | ADVANCED LIFE SUPPORT, LEVEL 2 [ALS 2] | 65% of current published Medicare rate* | 100% of current published Medicare rate*** | |||
A0434 | SPECIALTY CARE TRANSPORT [SCT] | 65% of current published Medicare rate* | 100% of current published Medicare rate*** | |||
A0435 | FIXED WING AIR MILEAGE, PER STATUTE MILE | 65% of current published Medicare rate* | 100% of current published Medicare rate*** | ** | ||
A0436 | ROTARY WING AIR MILEAGE, PER STATUTE MILE | 65% of current published Medicare rate* | 100% of current published Medicare rate*** | ** | ||
A0998 | AMBULANCE RESPONSE AND TREATMENT, NO TRANSPORT | $95.00 | $95.00 | |||
A0999 | UNLISTED AMBULANCE SERVICE (SEE NOTE A) | See Note A | YES | |||
*Maximum allowance set at 65% of the current published Medicare rate is effective March 1, 2015, and upon approval by CMS.
**All out of state services require prior authorization.
***Maximum allowance set at 100% of the current published Medicare rate is effective retroactive to January 1, 2020. The Department shall submit to CMS and anticipates approval for a State Plan Amendment related to these provisions.
C.M.R. 10, 144, ch. 101, ch. III, 144-101-III-5, subsec. 144-101-III-5.06