Ambulance
Transportation – 90%
Benefits
are provided for medically necessary services and supplies for licensed
ambulance transportation to the nearest hospital or Medicare-approved skilled
nursing facility which has the appropriate facilities to treat the
individual’s condition when the individual requires immediate medical
intervention as a result of a severe, life threatening or potentially disabling
condition, but only if any other means of transportation would seriously
endanger the individual’s life, or:
- Ambulance
service is from one hospital to another, including return, but only in
situations where evidence clearly establishes that the institution to which an
individual is being transferred is the nearest one having appropriate
facilities, equipment or staff physicians to treat the individual’s
condition or to obtain medically necessary diagnostic or therapeutic services
not available at the individual’s hospital or skilled nursing
facility.
- Licensed
air ambulance if
medically necessary and only when (1) the point of pickup is inaccessible by
land; or (2) great distances or other obstacles are involved in getting the
patient to the nearest appropriate facility, and speedy admission is essential.
If it is determined that a land ambulance would have sufficed, coverage will be
limited to the amount that would have been provided for a land ambulance.
Scheduled
air transports must be preauthorized with the Trust
Office.
If
the individual is transported beyond the nearest appropriate facility, benefits
are pro-rated accordingly.
Benefits are
not
provided for:
- Ambulance
use to or from the individual’s residence and a physician’s
office.
- Cabulance
services or any other commercial transportation.
- Transportation
for the individual’s or provider’s convenience.
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