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: 1. From your home, scene of accident or Medical Emergency to a Hospital; 2. Between Hospitals, including when we require you to move from an Out-of-Network Hospital to an In-Network Hospital; 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 ambulance Providers will be reimbursed at the lesser of the ambulance service providers rate or 180% of the Medicare rate for the transportation. Air and Water 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 or rotary wing transportation. For emergency services, we encourage your Provider(s) to coordinate with our Medical Management team in selecting an Air Ambulance provider, 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 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 Emergency ambulance services. Ambulance Services services are a Covered Service benefit when they are considered Medically Necessary and at least 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: 1. : o From your Your home, scene of an accident or Medical Emergency medical emergency to a Hospital; 2. ; o Between Hospitals, including when we We require you You to move from an Out-of-Network Hospital to an In-and In- Network Hospital; or 3. or o Between a Hospital and a Hospital, Skilled Nursing Facility (ground transport only) or Approved Facilityapproved facility. The Plan provides Benefits only for ambulance transportation You must be taken to the nearest Hospital facility that can provide give care for Your condition. During an appeal review, We may approve benefits for transportation to a facility that is not the required care you neednearest facility. Benefits also may include Medically Necessary treatment of a sickness or illness injury by medical professionals during an ambulance service, even if you You are not taken to a Facilityfacility. 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. Air and Water Ambulance Services are subject to Medical Necessity review by the PlanAlliant. For All scheduled ground ambulance services for non-emergency servicestransports, not including to acute facility to acute facility transport,must be Medically Necessary. This may include transportation from a Hospital, Skilled Nursing Facility or Rehabilitation Facility to Your residence when Your condition requires skilled monitoring during transport with the Plan services of an EMT attendant or other licensed healthcare practitioner. Air ambulance services are subject to Medical Necessity review by Alliant. Alliant retains the right to select the Air Ambulance air ambulance provider. This includes fixed wing, rotary wing or rotary wing water transportation. For Air ambulance services for non-emergency services, we encourage your Provider(s) Hospital to coordinate with our Medical Management team in selecting an Air Ambulance provider, when possible. Community Health Options has contracts with certain Air Ambulance providers and the Allowed Amount for Non-Network Air Ambulance Providers may Hospital transports must be based on those contracts. This means that you could be balance billed for charges that exceed the Allowed AmountMedically Necessary. Air Ambulance ambulance transport is for the purposes of transferring from one Hospital to another Hospital and is a Covered Service if such air ambulance transport is Medically Necessary and Necessary, for example, if transportation by ground ambulance would endanger your Your health and or the transferring Hospital does not have adequate facilities to provide the medical services needed. Examples of such specialized medical services that are generally not available at all types of facilities may include but are not limited to: burn care, cardiac care, trauma care, and critical care. Transport from one Hospital to another Hospital is Covered covered only if the Hospital to which you are being the patient is transferred is the nearest one with the 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 Emergency ambulance services. Ambulance Services services are a Covered Service benefit when they are considered Medically Necessary and at least 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: 1. : o From your Your home, scene of an accident or Medical Emergency medical emergency to a Hospital; 2. ; o Between Hospitals, including when we We require you You to move from an Out-of-Network Hospital to an In-and In- Network Hospital; or 3. or o Between a Hospital and a Hospital, Skilled Nursing Facility (ground transport only) or Approved Facilityapproved facility. The Plan provides Benefits only for ambulance transportation You must be taken to the nearest Hospital facility that can provide give care for Your condition. During an appeal review, We may approve benefits for transportation to a facility that is not the required care you neednearest facility. Benefits also may include Medically Necessary treatment of a sickness or illness injury by medical professionals during an ambulance service, even if you You are not taken to a Facilityfacility. NonOut-of-Network ambulance Providers will may xxxx You for charges that exceed the MAC for services that may be reimbursed at the lesser of the ambulance service providers rate or 180% of the Medicare rate for the transportationcovered but are non-emergent. Air and Water Ambulance Services are subject to Medical Necessity review by the PlanAlliant. For All scheduled ground ambulance services for non-emergency servicestransports, not including to acute facility to acute facility transport, must be Medically Necessary. This may include transportation from a Hospital, Skilled Nursing Facility or Rehabilitation Facility to Your residence when Your condition requires skilled monitoring during transport with the Plan services of an EMT attendant or other licensed healthcare practitioner. Air ambulance services are subject to Medical Necessity review by Alliant. Alliant retains the right to select the Air Ambulance air ambulance provider. This includes fixed wing, rotary wing or rotary wing water transportation. For Air ambulance services for non-emergency services, we encourage your Provider(s) Hospital to coordinate with our Medical Management team in selecting an Air Ambulance provider, when possible. Community Health Options has contracts with certain Air Ambulance providers and the Allowed Amount for Non-Network Air Ambulance Providers may Hospital transports must be based on those contracts. This means that you could be balance billed for charges that exceed the Allowed AmountMedically Necessary. Air Ambulance ambulance transport is for the purposes of transferring from one Hospital to another Hospital and is a Covered Service if such air ambulance transport is Medically Necessary and Necessary, for example, if transportation by ground ambulance would endanger your Your health and or the transferring Hospital does not have adequate facilities to provide the medical services needed. Examples of such specialized medical services that are generally not available at all types of facilities may include but are not limited to: burn care, cardiac care, trauma care, and critical care. Transport from one Hospital to another Hospital is Covered covered only if the Hospital to which you are being the patient is transferred is the nearest one with the 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: 1. From your home, scene of accident or Medical Emergency to a Hospital; 2. Between Hospitals, including when we require you to move from an Out-ofNon-Network Hospital to an In-Network Hospital; 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-emergent transportation services rendered by a Non-Network ambulance Providers will be reimbursed at the lesser of the ambulance service providers rate or 180% of the Medicare rate for the transportationProvider are not covered. Air and Water Ambulance Air and Water 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 or rotary wing transportation. For emergency services, we encourage your Provider(s) to coordinate with our Medical Management team in selecting an Air Ambulance provider, 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 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 Emergency ambulance services. Ambulance Services services are a Covered Service benefit when they are considered Medically Necessary and at least 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: 1. : o From your Your home, scene of accident an accident, or Medical Emergency medical emergency to a Hospital; 2. ; o Between Hospitals, including when we We require you You to move from an Out-of-Network Hospital to an In-Network Hospital; or 3. or o Between a Hospital and a Hospital, Skilled Nursing Facility (ground transport only) ), or Approved Facilityapproved facility. The Plan provides Benefits only for ambulance transportation You must be taken to the nearest Hospital facility that can provide give care for Your condition. During an appeal review, We may approve benefits for transportation to a facility that is not the required care you neednearest facility. Benefits also include Medically Necessary treatment of a sickness or illness Injury by medical professionals during an ambulance service, even if you You are not taken to a Facilityfacility. NonOut-of-Network ambulance Providers will may bill You for charges that exceed the MAC for services that may be reimbursed at the lesser of the ambulance service providers rate or 180% of the Medicare rate for the transportationcovered but are non-emergent. Air and Water Ambulance Services are subject to Medical Necessity review by the PlanAlliant. For All scheduled ground ambulance services for non-emergency servicestransports, not including to acute facility to acute facility transport, must be Medically Necessary. This may include transportation from a Hospital, Skilled Nursing Facility or Rehabilitation Facility to Your residence when Your condition requires skilled monitoring during transport with the Plan services of an EMT attendant or other licensed healthcare practitioner. Air ambulance services are subject to Medical Necessity review by Alliant. Alliant retains the right to select the Air Ambulance air ambulance provider. This includes fixed wing wing, rotary wing, or rotary wing water transportation. For Air ambulance services for non-emergency services, we encourage your Provider(s) Hospital to coordinate with our Medical Management team in selecting an Air Ambulance provider, when possible. Community Health Options has contracts with certain Air Ambulance providers and the Allowed Amount for Non-Network Air Ambulance Providers may Hospital transports must be based on those contracts. This means that you could be balance billed for charges that exceed the Allowed AmountMedically Necessary. Air Ambulance ambulance transport is for the purposes of transferring from one Hospital to another Hospital and is a Covered Service if such air ambulance transport is Medically Necessary and Necessary. For example, if transportation by ground ambulance would endanger your Your health and or the transferring Hospital does not have adequate facilities to provide the medical services needed. Examples of such specialized medical services that are generally not available at all types of facilities may include but are not limited to: burn care, cardiac care, trauma care, and critical care. Transport from one Hospital to another Hospital is Covered covered only if the Hospital to which you are being the patient is transferred is the nearest one with the 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 Emergency ambulance services. Ambulance Services services are a Covered Service benefit when they are considered Medically Necessary and at least 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: 1. : o From your home, scene of an accident or Medical Emergency medical emergency to a Hospital; 2. ; o Between Hospitals, including when we require you to move from an Out-of-Network Hospital to an In-and In- Network Hospital; or 3. or o Between a Hospital and a Hospital, Skilled Nursing Facility (ground transport only) or Approved Facilityapproved facility. The Plan provides Benefits only for ambulance transportation You must be taken to the nearest Hospital facility that can provide give care for your condition. During an appeal review, we may approve benefits for transportation to a facility that is not the required care you neednearest facility. Benefits also may include Medically Necessary treatment of a sickness or illness injury by medical professionals during an ambulance service, even if you are not taken to a Facilityfacility. NonOut-of-Network ambulance Providers will may xxxx you for charges that exceed the MAC for services that may be reimbursed at the lesser of the ambulance service providers rate or 180% of the Medicare rate for the transportationcovered but are non-emergent. Air and Water Ambulance Services are subject to Medical Necessity review by the PlanAlliant. For All scheduled ground ambulance services for non-emergency servicestransports, not including to acute facility to acute facility transport, must be Medically Necessary. This may include transportation from a Hospital, Skilled Nursing Facility or Rehabilitation Facility to your residence when your condition requires skilled monitoring during transport with the Plan services of an EMT attendant or other licensed healthcare practitioner. Air ambulance services are subject to Medical Necessity review by Alliant. Alliant retains the right to select the Air Ambulance air ambulance provider. This includes fixed wing, rotary wing or rotary wing water transportation. For Air ambulance services for non-emergency services, we encourage your Provider(s) Hospital to coordinate with our Medical Management team in selecting an Air Ambulance provider, when possible. Community Health Options has contracts with certain Air Ambulance providers and the Allowed Amount for Non-Network Air Ambulance Providers may Hospital transports must be based on those contracts. This means that you could be balance billed for charges that exceed the Allowed AmountMedically Necessary. Air Ambulance ambulance transport is for the purposes of transferring from one Hospital to another Hospital and is a Covered Service if such air ambulance transport is Medically Necessary and Necessary, for example, if transportation by ground ambulance would endanger your health and or the transferring Hospital does not have adequate facilities to provide the medical services needed. Examples of such specialized medical services that are generally not available at all types of facilities may include but are not limited to: burn care, cardiac care, trauma care, and critical care. Transport from one Hospital to another Hospital is Covered covered only if the Hospital to which you are being the patient is transferred is the nearest one with the 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.