Common use of Ambulance Service Clause in Contracts

Ambulance Service. The Plan provides Benefits for Medically Necessary ambulance services. Ambulance Services are a Covered Service when one or more of the following criteria are met: You are transported by a state licensed vehicle that is designed, equipped, and used only to transport the sick and injured and staffed by Emergency Medical Technicians (EMT), paramedics, or other certified medical professionals. This includes ground, fixed wing, rotary wing or water transportation. You are taken: a. From your home, scene of accident or medical Emergency to a Hospital; b. Between Hospitals, including when we require you to move from an Out-of-Network Hospital to an In-Network Hospital; or c. Between a Hospital and a Skilled Nursing Facility (ground transport only) or Approved Facility. The Plan provides Benefits only for ambulance transportation to the nearest Hospital that can provide the required care you need. Benefits also include Medically Necessary treatment of a sickness or illness by medical professionals during an ambulance service, even if you are not taken to a Facility. Non-Network Providers may bill you for any charges that exceed the Plan’s Maximum Allowed Amount (also known as balance billing). When there is an inadequate network, balance billing does not apply. Ambulance services are not covered when another type of transportation can be used without endangering your health. Ambulance services for your convenience or the convenience of your family or Provider are not Covered Services. Trips to a Provider’s office, clinic, morgue or funeral home are examples of non-covered ambulance services. Services are subject to Medical Necessity review by the Plan. Ambulance services are not covered when another type of transportation can be used without endangering your health. Ambulance services for your convenience or the convenience of your family or Provider are not Covered Services. Trips to a Provider’s office, clinic, morgue or funeral home are examples of non-covered ambulance services. Air Ambulance Services are subject to Medical Necessity review by the Plan. For non-emergency services, the Plan retains the right to select the Air Ambulance provider. This includes fixed wing, rotary wing, or water transportation. For emergency services, we encourage your Provider(s) to coordinate with our Medical Management team in selecting an Air Ambulance providers, when possible. Community Health Options has contracts with certain Air Ambulance providers and the Allowed Amount for non-Network Air Ambulance Providers may be based on those contracts. This means that you could be balance billed for charges that exceed the Allowed Amount. Air Ambulance transport from one Hospital to another Hospital is a Covered Service if Medically Necessary and if transportation by ground ambulance would endanger your health or the transferring Hospital does not have adequate facilities to provide the medical services needed. Transport from one Hospital to another Hospital is Covered only if the Hospital to which you are being transferred is the nearest one with medically appropriate facilities. Fixed wing or rotary wing air ambulance is furnished when your medical condition is such that transport by ground ambulance, in whole or in part, is not appropriate. Generally, transport by fixed wing or rotary wing air ambulance may be necessary because your condition requires rapid transport to a treatment facility, and either great distances or other obstacles preclude such rapid delivery to the nearest appropriate facility. Transport by fixed wing or rotary wing air ambulance may also be necessary because you are located in a place that is inaccessible to a ground or water ambulance provider.

Ambulance Service. The Plan provides Benefits for Medically Necessary ambulance services. Ambulance Services are a Covered Service when one or more of the following criteria are met: You are transported by a state licensed vehicle that is designed, equipped, and used only to transport the sick and injured and staffed by Emergency Medical Technicians (EMT), paramedics, or other certified medical professionals. This includes ground, fixed wing, rotary wing or water transportation. You are taken: a. From your home, scene of accident or medical Emergency to a Hospital; b. Between Hospitals, including when we require you to move from an Out-of-Network Out‐of‐Network Hospital to an In-Network In‐Network Hospital; or or c. Between a Hospital and a Skilled Nursing Facility (ground transport only) or Approved Facility. The Plan provides Benefits only for ambulance transportation to the nearest Hospital that can provide the required care you need. Benefits also include Medically Necessary treatment of a sickness or illness by medical professionals during an ambulance service, even if you are not taken to a Facility. Non-Network Non‐Network Providers may bill you for any non‐emergent charges that exceed the Plan’s Maximum Allowed Amount (also known as balance billing). When there is an inadequate network, balance billing does not apply. Ambulance services are not covered when another type Non‐Network ambulance Providers will be reimbursed at the lesser of transportation can be used without endangering your health. Ambulance services the ambulance service providers rate or 180% of the Medicare rate for your convenience or the convenience of your family or Provider are not Covered Services. Trips to a Provider’s office, clinic, morgue or funeral home are examples of non-covered ambulance servicestransportation. Services are subject to Medical Necessity review by the Plan. Ambulance services are not covered when another type of transportation can be used without endangering your health. Ambulance services for your convenience or the convenience of your family or Provider are not Covered Services. Trips to a Provider’s office, clinic, morgue or funeral home are examples of non-non‐ covered ambulance services. Air and Water Ambulance Services are subject to Medical Necessity review by the Plan. For non-emergency non‐emergency services, the Plan retains the right to select the Air Ambulance provider. This includes fixed wing, wing or rotary wing, or water wing transportation. For emergency services, we encourage your Provider(s) to coordinate with our Medical Management team in selecting an Air Ambulance providersprovider, when possible. Community Health Options has contracts with certain Air Ambulance providers and the Allowed Amount for non-Network non‐Network Air Ambulance Providers may be based on those contracts. This means that you could be balance billed for charges that exceed the Allowed Amount. Air Ambulance transport from one Hospital to another Hospital is a Covered Service if Medically Necessary and if transportation by ground ambulance would endanger your health or and the transferring Hospital does not have adequate facilities to provide the medical services needed. Transport from one Hospital to another Hospital is Covered only if the Hospital to which you are being transferred is the nearest one with medically appropriate facilities. Prior Approval requirements are applicable for admission. Fixed wing or rotary wing air ambulance is furnished when your medical condition is such that transport by ground ambulance, in whole or in part, is not medically appropriate. Generally, transport by fixed wing or rotary wing air ambulance may be necessary because your condition requires rapid transport to a treatment facility, and either great distances or other obstacles preclude such rapid delivery to the nearest appropriate facility. Transport by fixed wing or rotary wing air ambulance may also be medically necessary because you are located in a place that is inaccessible to a ground or water ambulance provider.

Ambulance Service. The Plan provides Benefits for Medically Necessary ambulance services. Ambulance Services are a Covered Service when one or more of the following criteria are met: You are transported by a state licensed vehicle that is designed, equipped, and used only to transport the sick and injured and staffed by Emergency Medical Technicians (EMT), paramedics, or other certified medical professionalsprofe ssionals. This includes ground, fixed wing, rotary wing or water transportation. You are taken: a. From your home, scene of accident or medical Emergency to a Hospital; b. Between Hospitals, including when we require you to move from an Out-of-Out - of- Network Hospital to t o an In-In - SAMPLE Network Hospital; or or c. Between a Hospital and a Skilled Nursing Facility (ground transport only) or Approved Facility. The Plan provides Benefits only for ambulance transportation to the nearest Hospital that can provide the required care you need. Benefits also include Medically Necessary treatment of a sickness or illness by medical professionals during an ambulance service, even if you are not taken to a Facility. Non-Network Providers may bill you for any charges that exceed the Plan’s Maximum Non- Allowed Amount (also known as balance billing)) . When there is an inadequate network, balance billing does not apply. Ambulance services are not covered when another type of transportation can be used without endangering your health. Ambulance services for your convenience or the convenience of your family or Provider are not Covered Services. Trips to a Provider’s office, clinic, morgue or funeral home are examples of non-- covered ambulance services. Ground Ambulance Services are subject to Medical Necessity Necess ity review by the Plan. Ambulance services are not covered when another type of transportation can be used without endangering your health. Ambulance services for your convenience or the convenience of your family or Provider are not Covered Services. Trips to a Provider’s Tr office, clinic, morgue or funeral home are examples of non-non - covered ambulance services. Air Ambulance Services are subject to Medical Necessity review by the Plan. For non-non - emergency services, the t he Plan retains the th e right to select the Air Ambulance provider. This includes fixed wing, rotary wing, or water transportation. For emergency services, we encourage your Provider(s) to coordinate with our Medical Management team in selecting an Air Ambulance providersprovider, when whe n possible. Community Health Options has contracts with certain Air Ambulance providers and the Allowed Amount for non-non - Network Air Ambulance Providers may be based on those contracts. This means that you could be balance billed for charges that exceed the th e Allowed Amount. Air Ambulance transport from one Hospital to another Hospital is a Covered Service if Medically Necessary and if transportation by ground ambulance would endanger your health or and the transferring Hospital does not have adequate facilities facilitie s to provide the medical services needed. Transport from one Hospital to another Hospital is Covered only if the Hospital to which you are being transferred is the nearest one with medically appropriate facilities. Prior Approval requirements are applica ble for admission. Fixed wing or rotary wing air ambulance is furnished when your medical condition is such that transport by ground ambulance, in whole or in part, is not appropriate. Generally, transport by fixed wing or rotary wing air ambulance may be necessary because your condition requires rapid transport to a treatment facility, and either great distances or other obstacles preclude such rapid delivery to the nearest appropriate facility. Transport by fixed wing or rotary wing air ambulance may also be necessary because you are located in a place that is inaccessible to a ground or water ambulance provider.appropriate

Ambulance Service. The Plan provides Benefits for Medically Necessary ambulance services. Ambulance Services are a Covered Service when one or more of the following criteria are met: You are transported by a state licensed vehicle that is designed, equipped, and used only to transport the sick and injured and staffed by Emergency Medical Technicians (EMT), paramedics, or other certified medical professionals. This includes ground, fixed wing, rotary wing or water transportation. You are taken: a. From your home, scene of accident or medical Emergency to a Hospital; b. Between Hospitals, including when we require you to move from an Out-of-Network Hospital to an In-In- Network Hospital; or c. Between a Hospital and a Skilled Nursing Facility (ground transport only) or Approved Facility. The Plan provides Benefits only for ambulance transportation to the nearest Hospital that can provide the required care you need. Benefits also include Medically Necessary treatment of a sickness or illness by medical professionals during an ambulance service, even if you are not taken to a Facility. Non-Network Providers may bill you for any charges that exceed the Plan’s Maximum Allowed Amount (also known as balance billing). When there is an inadequate network, balance billing does not apply. Out- of-Network ambulance Providers will be reimbursed at the lesser of the ambulance service providers rate or 180% of the Medicare rate for the transportation. SAMPLE Ambulance services are not covered when another type of transportation can be used without endangering your health. Ambulance services for your convenience or the convenience of your family or Provider are not Covered Services. Trips to a Provider’s office, clinic, morgue or funeral home are examples of non-covered ambulance services. Services are subject to Medical Necessity review by the Plan. Ambulance services are not covered when another type of transportation can be used without endangering your health. Ambulance services for your convenience or the convenience of your family or Provider are not Covered Services. Trips to a Provider’s office, clinic, morgue or funeral home are examples of non-covered ambulance services. Air Ambulance Services are subject to Medical Necessity review by the Plan. For non-emergency services, the Plan retains the right to select the Air Ambulance provider. This includes fixed wing, wing or rotary wing, or water wing transportation. For emergency services, we encourage your Provider(s) to coordinate with our Medical Management team in selecting an Air Ambulance providersprovider, when possible. Community Health Options has contracts with certain Air Ambulance providers and the Allowed Amount for non-Network Air Ambulance Providers may be based on those contracts. This means that you could be balance billed for charges that exceed the Allowed Amount. When there is an inadequate network, balance billing does not apply. Air Ambulance transport from one Hospital to another Hospital is a Covered Service if Medically Necessary and if transportation by ground ambulance would endanger your health or and the transferring Hospital does not have adequate facilities to provide the medical services needed. Transport from one Hospital to another Hospital is Covered only if the Hospital to which you are being transferred is the nearest one with medically appropriate facilities. Prior Approval requirements are applicable for admission. Fixed wing or rotary wing air ambulance is furnished when your medical condition is such that transport by ground ambulance, in whole or in part, is not medically appropriate. Generally, transport by fixed wing or rotary wing air ambulance may be necessary because your condition requires rapid transport to a treatment facility, and either great distances or other obstacles preclude such rapid delivery to the nearest appropriate facility. Transport by fixed wing or rotary wing air ambulance may also be medically necessary because you are located in a place that is inaccessible to a ground or water ambulance provider.

Ambulance Service. The Plan provides Benefits for Medically Necessary ambulance services. Ambulance Services are a Covered Service when one or more of the following criteria are met: You are transported by a state licensed vehicle that is designed, equipped, and used only to transport the sick and injured and staffed by Emergency Medical Technicians (EMT), paramedics, or other certified medical professionals. This includes ground, fixed wing, rotary wing or water transportation. You are taken: a. 1. From your home, scene of accident or medical Medical Emergency to a Hospital; b. 2. Between Hospitals, including when we require you to move from an Out-of-Network Hospital to an In-In- Network Hospital; or c. 3. Between a Hospital and a Skilled Nursing Facility (ground transport only) or Approved Facility. The Plan provides Benefits only for ambulance transportation to the nearest Hospital that can provide the required care you need. Benefits also include Medically Necessary treatment of a sickness or illness by medical professionals during an ambulance service, even if you are not taken to a Facility. Non-Network Providers may bill you for any charges that exceed the Plan’s Maximum Allowed Amount (also known as balance billing). When there is an inadequate network, balance billing does not apply. Non- Network Providers may bill you for any charges that exceed the Plan’s Maximum Allowed Amount (also known as balance billing). Out-of-Network ambulance Providers will be reimbursed at the lesser of the ambulance service providers rate or 180% of the Medicare rate for the transportation. Ambulance services are not covered when another type of transportation can be used without endangering your health. Ambulance services for your convenience or the convenience of your family or Provider are not Covered Services. Trips to a Provider’s office, clinic, morgue or funeral home are examples of non-covered ambulance services. Services are subject to Medical Necessity review by the Plan. Ambulance services are not covered when another type of transportation can be used without endangering your health. Ambulance services for your convenience or the convenience of your family or Provider are not Covered Services. Trips to a Provider’s office, clinic, morgue or funeral home are examples of non-covered ambulance services. Air Ambulance Services are subject to Medical Necessity review by the Plan. For non-emergency services, the Plan retains the right to select the Air Ambulance provider. This includes fixed wing, wing or rotary wing, or water wing transportation. For emergency services, we encourage your Provider(s) to coordinate with our Medical Management team in selecting an Air Ambulance providersprovider, when possible. Community Health Options has contracts with certain Air Ambulance providers and the Allowed Amount for non-Network Air Ambulance Providers may be based on those contracts. This means that you could be balance billed for charges that exceed the Allowed Amount. Air Ambulance transport from one Hospital to another Hospital is a Covered Service if Medically Necessary and if transportation by ground ambulance would endanger your health or and the transferring Hospital does not have adequate facilities to provide the medical services needed. Transport from one Hospital to another Hospital is Covered only if the Hospital to which you are being transferred is the nearest one with medically appropriate facilities. Prior Approval requirements are applicable for admission. Fixed wing or rotary wing air ambulance is furnished when your medical condition is such that transport by ground ambulance, in whole or in part, is not medically appropriate. Generally, transport by fixed wing or rotary wing air ambulance may be necessary because your condition requires rapid transport to a treatment facility, and either great distances or other obstacles preclude such rapid delivery to the nearest appropriate facility. Transport by fixed wing or rotary wing air ambulance may also be medically necessary because you are located in a place that is inaccessible to a ground or water ambulance provider.

Ambulance Service. The Plan provides Benefits for Medically Necessary ambulance services. Ambulance Services are a Covered Service when one or more of the following criteria are met: You are transported by a state licensed vehicle that is designed, equipped, and used only to transport the sick and injured and staffed by Emergency Medical Technicians (EMT), paramedics, or other certified medical professionals. This includes ground, fixed wing, rotary wing or water transportation. You are taken: a. From your home, scene of accident or medical Emergency to a Hospital; b. Between Hospitals, including when we require you to move from an Out-of-Network Hospital to an In-Network Hospital; or c. Between a Hospital and a Skilled Nursing Facility (ground transport only) or Approved Facility. The Plan provides Benefits only for ambulance transportation to the nearest Hospital that can provide the required care you need. Benefits also include Medically Necessary treatment of a sickness or illness by medical professionals during an ambulance service, even if you are not taken to a Facility. Non-Network Providers may bill you for any charges that exceed the Plan’s Maximum Allowed Amount (also known as balance billing). When there is an inadequate network, balance billing does not apply. Ambulance services are not covered when another type of transportation can be used without endangering your health. Ambulance services for your convenience or the convenience of your family or Provider are not Covered Services. Trips to a Provider’s office, clinic, morgue or funeral home are examples of non-covered ambulance services. Services are subject to Medical Necessity review by the Plan. Ambulance services are not covered when another type of transportation can be used without endangering your health. Ambulance services for your convenience or the convenience of your family or Provider are not Covered Services. Trips to a Provider’s office, clinic, morgue or funeral home are examples of non-covered ambulance services. Air Ambulance Services are subject to Medical Necessity review by the Plan. For non-emergency services, the Plan retains the right to select the Air Ambulance provider. This includes fixed wing, rotary wing, or water transportation. For emergency services, we encourage your Provider(s) to coordinate with our Medical Management team in selecting an Air Ambulance providersprovider, when possible. Community Health Options has contracts with certain Air Ambulance providers and the Allowed Amount for non-Network Air Ambulance Providers may be based on those contracts. This means that you could be balance billed for charges that exceed the Allowed Amount. When there is an inadequate network, balance billing does not apply. Air Ambulance transport from one Hospital to another Hospital is a Covered Service if Medically Necessary and if transportation by ground ambulance would endanger your health or the transferring Hospital does not have adequate facilities to provide the medical services needed. Transport from one Hospital to another Hospital is Covered only if the Hospital to which you are being transferred is the nearest one with medically appropriate facilities. Fixed wing or rotary wing air ambulance is furnished when your medical condition is such that transport by ground ambulance, in whole or in part, is not appropriate. Generally, transport by fixed wing or rotary wing air ambulance may be necessary because your condition requires rapid transport to a treatment facility, and either great distances or other obstacles preclude such rapid delivery to the nearest appropriate facility. Transport by fixed wing or rotary wing air ambulance may also be necessary because you are located in a place that is inaccessible to a ground or water ambulance provider.

Ambulance Service. The Plan provides Benefits for Medically Necessary ambulance services. Ambulance Services are a Covered Service when one or more of the following criteria are met: You are transported by a state licensed vehicle that is designed, equipped, and used only to transport the sick and injured and staffed by Emergency Medical Technicians (EMT), paramedics, or other certified medical professionals. This includes ground, fixed wing, rotary wing wing, or water transportation. You are taken: a. 1. From your home, scene of accident or medical Medical Emergency to a Hospital; b. 2. Between Hospitals, including when we require you to move from an Out-of-Network Out‐of‐Network Hospital to an In-Network In‐Network Hospital; or c. or 3. Between a Hospital and a Skilled Nursing Facility (ground transport only) or Approved Facility. The Plan provides Benefits only for ambulance transportation to the nearest Hospital that can provide the required care you need. Benefits also include Medically Necessary treatment of a sickness or illness by medical professionals during an ambulance service, even if you are not taken to a Facility. Non-Network Non‐Network Providers may bill you for any non‐emergent charges that exceed the Plan’s Maximum Allowed Amount (also known as balance billing). When there is an inadequate network, balance billing does not apply. Ambulance services are not covered when another type Non‐Network Providers may bill you for any charges that exceed the Plan’s Maximum Allowed Amount (also known as balance billing). Out‐of‐Network ambulance Providers will be reimbursed at the lesser of transportation can be used without endangering your health. Ambulance services the ambulance service providers rate or 180% of the Medicare rate for your convenience or the convenience of your family or Provider are not Covered Services. Trips to a Provider’s office, clinic, morgue or funeral home are examples of non-covered ambulance servicestransportation. Services are subject to Medical Necessity review by the Plan. Ambulance services are not covered when another type of transportation can be used without endangering your health. Ambulance services for your convenience or the convenience of your family or Provider are not Covered Services. Trips to a Provider’s office, clinic, morgue morgue, or funeral home are examples of non-covered non‐covered ambulance services. Air and Water Ambulance Services are subject to Medical Necessity review by the Plan. For non-emergency non‐emergency services, the Plan retains the right to select the Air Ambulance provider. This includes fixed wing, wing or rotary wing, or water wing transportation. For emergency services, we encourage your Provider(s) to coordinate with our Medical Management team in selecting an Air Ambulance providersprovider, when possible. Community Health Options has contracts with certain Air Ambulance providers and the Allowed Amount for non-Network non‐Network Air Ambulance Providers may be based on those contracts. This means that you could be balance billed for charges that exceed the Allowed Amount. Air Ambulance transport from one Hospital to another Hospital is a Covered Service if Medically Necessary and if transportation by ground ambulance would endanger your health or and the transferring Hospital does not have adequate facilities to provide the medical services needed. Transport from one Hospital to another Hospital is Covered only if the Hospital to which you are being transferred is the nearest one with medically appropriate facilities. Prior Approval requirements are applicable for admission. Fixed wing or rotary wing air ambulance is furnished when your medical condition is such that transport by ground ambulance, in whole or in part, is not medically appropriate. Generally, transport by fixed wing or rotary wing air ambulance may be necessary because your condition requires rapid transport to a treatment facility, and either great distances or other obstacles preclude such rapid delivery to the nearest appropriate facility. Transport by fixed wing or rotary wing air ambulance may also be medically necessary because you are located in a place that is inaccessible to a ground or water ambulance provider.

Ambulance Service. The Plan provides Benefits for Medically Necessary ambulance services. Ambulance Services are a Covered Service when one or more of the following criteria are met: You are transported by a state licensed vehicle that is designed, equipped, and used only to transport the sick and injured and staffed by Emergency Medical Technicians (EMT), paramedics, or other certified medical professionals. This includes ground, fixed wing, rotary wing or water transportation. You are taken: a. From your home, scene of accident or medical Emergency to a Hospital;; SAMPLE b. Between Hospitals, including when we require you to move from an Out-of-Network Hospital to an In-Network Hospital; or c. Between a Hospital and a Skilled Nursing Facility (ground transport only) or Approved Facility. The Plan provides Benefits only for ambulance transportation to the nearest Hospital that can provide the required care you need. Benefits also include Medically Necessary treatment of a sickness or illness by medical professionals during an ambulance service, even if you are not taken to a Facility. Non-Network Providers may bill you for any charges that exceed the Plan’s Maximum Allowed Amount (also known as balance billing). When there is an inadequate network, balance billing does not apply. Non-Network ambulance Providers will be reimbursed at the lesser of the ambulance service providers rate or 180% of the Medicare rate for the transportation. Ambulance services are not covered when another type of transportation can be used without endangering your health. Ambulance services for your convenience or the convenience of your family or Provider are not Covered Services. Trips to a Provider’s office, clinic, morgue or funeral home are examples of non-covered ambulance services. Services are subject to Medical Necessity review by the Plan. Ambulance services are not covered when another type of transportation can be used without endangering your health. Ambulance services for your convenience or the convenience of your family or Provider are not Covered Services. Trips to a Provider’s office, clinic, morgue or funeral home are examples of non-covered ambulance services. Air Ambulance Services are subject to Medical Necessity review by the Plan. For non-emergency services, the Plan retains the right to select the Air Ambulance provider. This includes fixed wing, wing or rotary wing, or water wing transportation. For emergency services, we encourage your Provider(s) to coordinate with our Medical Management team in selecting an Air Ambulance providersprovider, when possible. Community Health Options has contracts with certain Air Ambulance providers and the Allowed Amount for non-non- Network Air Ambulance Providers may be based on those contracts. This means that you could be balance billed for charges that exceed the Allowed Amount. Air Ambulance transport from one Hospital to another Hospital is a Covered Service if Medically Necessary and if transportation by ground ambulance would endanger your health or and the transferring Hospital does not have adequate facilities to provide the medical services needed. Transport from one Hospital to another Hospital is Covered only if the Hospital to which you are being transferred is the nearest one with medically appropriate facilities. Prior Approval requirements are applicable for admission. Fixed wing or rotary wing air ambulance is furnished when your medical condition is such that transport by ground ambulance, in whole or in part, is not medically appropriate. Generally, transport by fixed wing or rotary wing air ambulance may be necessary because your condition requires rapid transport to a treatment facility, and either great distances or other obstacles preclude such rapid delivery to the nearest appropriate facility. Transport by fixed wing or rotary wing air ambulance may also be medically necessary because you are located in a place that is inaccessible to a ground or water ambulance provider.

Ambulance Service. The Plan provides Benefits for Medically Necessary ambulance services. Ambulance Services are a Covered Service when one or more of the following criteria are met: You are transported by a state licensed vehicle that is designed, equipped, and used only to transport the sick and injured and staffed by Emergency Medical Technicians (EMT), paramedics, or other certified medical professionals. This includes ground, fixed wing, rotary wing or water transportation. You are taken: a. 1. From your home, scene of accident or medical Medical Emergency to a Hospital; b. 2. Between Hospitals, including when we require you to move from an Out-of-Network Hospital to an In-Network Hospital; or c. 3. Between a Hospital and a Skilled Nursing Facility (ground transport only) or Approved Facility. SAMPLE The Plan provides Benefits only for ambulance transportation to the nearest Hospital that can provide the required care you need. Benefits also include Medically Necessary treatment of a sickness or illness by medical professionals during an ambulance service, even if you are not taken to a Facility. Non-Network Providers may bill you for any charges that exceed the Plan’s Maximum Allowed Amount (also known as balance billing). When there is an inadequate network, balance billing does not apply. Non-Network Providers may bill you for any charges that exceed the Plan’s Maximum Allowed Amount (also known as balance billing). Out-of-Network ambulance Providers will be reimbursed at the lesser of the ambulance service providers rate or 180% of the Medicare rate for the transportation. Ambulance services are not covered when another type of transportation can be used without endangering your health. Ambulance services for your convenience or the convenience of your family or Provider are not Covered Services. Trips to a Provider’s office, clinic, morgue or funeral home are examples of non-covered ambulance services. Services are subject to Medical Necessity review by the Plan. Ambulance services are not covered when another type of transportation can be used without endangering your health. Ambulance services for your convenience or the convenience of your family or Provider are not Covered Services. Trips to a Provider’s office, clinic, morgue or funeral home are examples of non-covered ambulance services. Air Ambulance Services are subject to Medical Necessity review by the Plan. For non-emergency services, the Plan retains the right to select the Air Ambulance provider. This includes fixed wing, wing or rotary wing, or water wing transportation. For emergency services, we encourage your Provider(s) to coordinate with our Medical Management team in selecting an Air Ambulance providersprovider, when possible. Community Health Options has contracts with certain Air Ambulance providers and the Allowed Amount for non-non- Network Air Ambulance Providers may be based on those contracts. This means that you could be balance billed for charges that exceed the Allowed Amount. Air Ambulance transport from one Hospital to another Hospital is a Covered Service if Medically Necessary and if transportation by ground ambulance would endanger your health or and the transferring Hospital does not have adequate facilities to provide the medical services needed. Transport from one Hospital to another Hospital is Covered only if the Hospital to which you are being transferred is the nearest one with medically appropriate facilities. Prior Approval requirements are applicable for admission. Fixed wing or rotary wing air ambulance is furnished when your medical condition is such that transport by ground ambulance, in whole or in part, is not medically appropriate. Generally, transport by fixed wing or rotary wing air ambulance may be necessary because your condition requires rapid transport to a treatment facility, and either great distances or other obstacles preclude such rapid delivery to the nearest appropriate facility. Transport by fixed wing or rotary wing air ambulance may also be medically necessary because you are located in a place that is inaccessible to a ground or water ambulance provider.

Ambulance Service. The Plan provides Benefits for Medically Necessary ambulance services. Ambulance Services are a Covered Service when one or more of the following criteria are met: You are transported by a state licensed vehicle that is designed, equipped, and used only to transport the sick and injured and staffed by Emergency Medical Technicians (EMT), paramedics, or other certified medical professionals. This includes ground, fixed wing, rotary wing or water transportation. You are taken: a. 1. From your home, scene of accident or medical Emergency to a Hospital; b. 2. Between Hospitals, including when we require you to move from an Out-of-Network Hospital to an In-Network Hospital; or c. 3. Between a Hospital and a Skilled Nursing Facility (ground transport only) or Approved Facility. The Plan provides Benefits only for ambulance transportation to the nearest Hospital that can provide the required care you need. Benefits also include Medically Necessary treatment of a sickness or illness by medical professionals during an ambulance service, even if you are not taken to a Facility. Non-Network Providers may bill you for any charges that exceed the Plan’s Maximum Allowed Amount (also known as balance billing). When there is an inadequate network, balance billing does not apply. Ambulance services are not covered when another type of transportation can be used without endangering your health. Ambulance services for your convenience or the convenience of your family or Provider are not Covered Services. Trips to a Provider’s office, clinic, morgue or funeral home are examples of non-covered ambulance services. Services are subject to Medical Necessity review by the Plan. Ambulance services are not covered when another type of transportation can be used without endangering your health. Ambulance services for your convenience or the convenience of your family or Provider are not Covered Services. Trips to a Provider’s office, clinic, morgue or funeral home are examples of non-covered ambulance services. Air Ambulance Services are subject to Medical Necessity review by the Plan. For non-emergency services, the Plan retains the right to select the Air Ambulance provider. This includes fixed wing, rotary wing, or water transportation. For emergency services, we encourage your Provider(s) to coordinate with our Medical Management team in selecting an Air Ambulance providersprovider, when possible. Community Health Options has contracts with certain Air Ambulance providers and the Allowed Amount for non-Network Air Ambulance Providers may be based on those contracts. This means that you could be balance billed for charges that exceed the Allowed Amount. Air Ambulance transport from one Hospital to another Hospital is a Covered Service if Medically Necessary and if transportation by ground ambulance would endanger your health or the transferring Hospital does not have adequate facilities to provide the medical services needed. Transport from one Hospital to another Hospital is Covered only if the Hospital to which you are being transferred is the nearest one with medically appropriate facilities. Fixed wing or rotary wing air ambulance is furnished when your medical condition is such that transport by ground ambulance, in whole or in part, is not appropriate. Generally, transport by fixed wing or rotary wing air ambulance may be necessary because your condition requires rapid transport to a treatment facility, and either great distances or other obstacles preclude such rapid delivery to the nearest appropriate facility. Transport by fixed wing or rotary wing air ambulance may also be necessary because you are located in a place that is inaccessible to a ground or water ambulance provider.