Your Questions

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Your Questions

Q: Recently my disabled mother needed ambulance service, but Medicare denied the claim. What went wrong?

A: First, check the “Explanation of Benefits” from Medicare to see why the claim was denied. If you think Medicare made a mistake, call the phone number on the Medicare notice and ask the service representative to review the denial with you. The most common reason for payment to be denied is that Medicare does not have appropriate documentation for your claim. Medicare generally will reimburse for ambulance transports if the patient was:

Transported by a Medicare-approved ambulance company. Some area rescue squads provide this service, as well as private ambulance companies. If the service is not Medicare certified and they charge a fee, Medicare may not pay your bill.

Suffering from an illness or injury to the degree that other forms of transportation would not have been “contraindicated.”

Transported between the following points: (a) patient’s home to a hospital or skilled nursing home, (b) skilled nursing home to hospital or hospital to skilled nursing home, (c) hospital to hospital or skilled home to skilled nursing home (d) hospital or skilled nursing home to patient’s home.

Appropriate documentation has been supplied to Medicare to verify the patient’s illness or injury was such an emergency nature that “the absence of immediate medical attention could reasonably be expected to result in serious jeopardy to the patient’s health, serious impairment to bodily functions, or serious dysfunction of any body organ or part.”

Medicare may deny claim if your mother was not bed-confined and she used an ambulance for non-emergency transportation. Bed-confined means unable to sit in a wheelchair or chair for the length of the trip.

This situation can be resolved in your favor if you have your doctor send the appropriate diagnosis and supporting documentation to Medicare. If you feel that Medicare has wrongly denied your claim—appeal! Follow the appeal guidelines located on the back of your “Explanation of Benefits” or the “Medicare Summary Notice.” In many cases a Certification of Medical Necessity from your doctor may be all that is needed to have the claim approved.

If you have any questions or if you have other health insurance concerns, call your local Area Board For Aging. Free health insurance counseling is available. To find the Agency in your area, call The Eldercare Locator at 800-677-1116 or go to http://www.eldercare.gov.

This article first appeared in Volume 5, Issue 5 of "The Social Security and Medicare Advisor" newsletter (April/2000). To receive future editions of "The Advisor" in its special, free e-mail version, please click here.