Denials & Appeals
Not all Transports are Alike…Connecting the Dots.
Health Insurance providers may not cover all ambulance transports, claims that have been denied typically are denied for the following reasons:
- Ambulance is not a covered service
- Use of the ambulance was determined by the carrier to not be medically necessary (see tab on Medical Necessity)
- Portions of mileage can be denied. As a general rule, medically necessary ambulance transportation is covered to nearest appropriate facility. When the ambulance transport goes beyond the nearest appropriate facility, Medicare will only make partial payment from the point of pick up to nearest appropriate facility.
If a claim has been determined to have been not medically necessary, there are some specific things that you can do. Many carriers have a review process in which previously denied claims can be resubmitted, with additional information, for further consideration. This additional information involves obtaining additional medical information from the physician, which is your responsibility, in order to make a determination that the use of an ambulance was medically necessary.
The information must be very specific in nature – a doctor writing a letter just stating, “ambulance service was medically necessary” will normally be denied on review. If the claim has been denied as “not medically necessary” because the physician did not submit a Physician’s Certification Statement (PCS) within the required twenty-one (21) days, there is no appeal process available under federal rules. The patient needs to contact their physician and determine why the physician failed to provide a PCS within the required time frame in accordance with Federal Rules and Regulations.
As a Medicare Recipient you have the right to file an appeal. For your convenience we have included some of the necessary links to help you file your appeal with Medicare should you decide to do so. However, we encourage you to contact our Billing Office first for assistance.
1. Obtain a letter from your personal physician stating why (in detail) it was medically necessary for you to be transported to the hospital by ambulance.
2. You may need to submit a copy of the ambulance run report.
3. You may need to obtain a copy of your medical records from the hospital. (You must obtain these records yourself and may be required to pay a fee to the hospital.)
4. Complete the Medicare Redetermination Request Form. (see our Forms Tab)
5. Mail the above items to:
Medicare Part B – Reviews
P.O. Box 2360
Jacksonville, Fl 32231-0018
In order for Medicare to reconsider your ambulance bill, you should file an appeal within 120 days from the date of Medicare’s original denial letter. Your appeal should be mailed well in advance of the deadline since Medicare’s date of denial determines whether they will consider your case.
Note: This information is for educational purposes and familiarization with some of the healthcare insurance practices only. We are not stating health care regulation or rules, and we encourage each person to contact their carrier and plan administrator.
For more information about Medicare please consider reviewing the information at to the following link.