Medical Necessity

Medical Necessity

Necessity is the Mother of Invention

Health Insurance providers and Medicare in particular have strict guidelines on what they will cover and what is deemed as “medically necessary”.

For the service to be determined medically necessary, the patient’s medical condition at the time of transport must be such that any other means of transportation would have placed the patient’s life in danger.

In addition, Medicare and Medicaid have guidelines requiring all non-emergency ambulance transports from a hospital, nursing home, physician’s office, out-patient facility or clinic to obtain a Physician’s Certification statement (PCS). We collect this statement at the time the request for service is received.

However, if the PCS is not submitted with the ambulance service within twenty-one (21) days of transport, including holidays and weekends, the claim must be submitted to Medicare as “Not Medically Necessary” resulting in the claim being denied and the patient becoming responsible for the full amount of the ambulance bill. Our team works diligently in conjunction with your healthcare providers to ensure that all needed forms are obtained.

We will only bill for claims that meet the requirements for medical necessity. We have provided a sample of some general guidelines on what many insurance companies will cover. For information concerning what your insurance policy covers you need to contact your insurance agency or plan administrator.

In general, it does NOT include transports to:
  • Physician or Doctor’s Offices
  • Out Patient Treatment Facilities
  • Urgent Care Centers
  • Hospitals outside the immediate service area
  • Transports to other non-medical facilities
  • Non-medical stretcher or wheelchair transports

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.