June 1, 2001

MEDICARE

Part B Carrier

June 1, 2001

Dear Ambulance Supplier,

This letter contains important information regarding reimbursement rates for ambulance services rendered on or after July 1, 2001. In a letter dated January 26, 2001, we notified you of reimbursement rates effective for dates of service January 1, 2001. Effective for dates of service July 1, 2001, an additional change to the rates is needed as a result of §423 of the Benefits Improvement and Protection Act (BIPA) of 2000.

The reasonable charge update factor applicable to ambulance services rendered January 1, 2001 and after was 2.7 percent. For ambulance services rendered July 1, 2001 and after, the reasonable charge update factor is 4.7 percent. The allowance for ambulance services rendered July 1, 2001 and after, therefore, will be based on 100 percent of the reasonable charge amounts from the year 2000 increased by the ambulance inflation factor (AIF) of 4.7 percent.

A separate fee schedule for each locality is attached to this letter. To determine the reimbursement rates effective for services rendered on or after January 1, 2001, and for services rendered on or after July 1, 2001, refer to the attachment for the appropriate locality and the chart for the appropriate billing method:

Attachment	Locality	Counties
Attachment I	Locality 11	Bergen, Essex, Hudson, Hunterdon, Middlesex, Morris, Passaic, Somerset, Sussex, Union, Warren
Attachment II	Locality 12	Burlington, Mercer, Monmouth, Ocean
Attachment III	Locality 13	Atlantic, Camden, Cape May, Cumberland, Gloucester, Salem

The fee schedules display the prevailing 75^th and 50^th percentile amounts as well as the IIC for each New Jersey locality for each reimbursement period of 2001. The Medicare allowance is the lowest of 1) the submitted charge, 2) the customary amount, or 3) the prevailing 75^th or prevailing IIC. (If a customary amount is not applicable, item 2 is substituted with the prevailing 50^th percentile.) To request information regarding your customary charge history, write to the Freedom of Information Act (FOIA) department at P. O. Box 69209, Harrisburg, PA 17106-9209.

Documentation regarding this change can be found on the Health Care Financing Administration’s (HCFA) web site http://cms.hhs.gov/, transmittal AB-01-22. Additionally, other ambulance-related program memos are listed.

This letter also includes important billing reminders. By applying these reminders, you will help us to provide you with efficient and timely processing of your ambulance claims.

Billing Reminders

The zip code of the point of pickup must be reported with the claim. Claims submitted with incomplete or invalid zip codes will be rejected. The zip code should be reported as follows:

1500 claim form - report the 5 digit zip code in Block 23
1491 claim form - report the 5 digit zip code in Block 12
Electronic Data Interchange (EDI) submission - report as follows:

Data

NSF (1.04, 2.00, 3.01)

ANSI X12 837 (3032, 3051)

ANSI X12 837 (4010 – HIPAA)

Point of Pickup Address information

Street Address – EA1.06, positions 53-82

City – EA1.08, positions 113-132

State – EA1.09, positions 133-134

Zip code – EA1.10, positions 135-143

In Loop 2310A, segment NM1, report:

Qualifier ‘61’ in NM101, qualifier ‘2’ in NM102.

In Loop 2310A, segment N4, report:

City name in N401, State code in N402, zip code in N403

In Loop 2310D, segment NM1, report:

Qualifier ‘77’ in NM101, qualifier ‘2’ in NM102.

In Loop 2310D, segment N4, report:

City name in N401, State code in N402, zip code in N403

More than one ambulance trip may be reported on the same claim for a beneficiary if all points of pickup have the same zip code. Suppliers must prepare a separate claim for each trip if the points of pickup are located in different zip codes.

1500 claim form - When the point of pickup zip codes are reported in Block 32 and they do not match the zip code reported in block 23, submit a separate claim for each portion of the transport.

1491claim form - When the zip codes reported in blocks 12 and 13 do not match, submit a separate claim for each portion of the transport.

EDI - When the zip codes reported for the points of pickup do not match, submit a separate claim for each portion of the transport.

Please indicate "round trip" on the claim in appropriate fields when preparing separate claims for round trip zip code requirements:

1500 claim form - Block 19

1491 claim form - Block 22

EDI - Narrative OR in the TRANS TYPE field, key "X." (Note: Use an "X" in the TRANS TYPE field for both portions of a round trip.)

For round trip outpatient services, report the type of service(s) performed at the facility. Please report the type of service on each claim when separate claims are prepared for round trips.

Report valid origin and destination modifier(s) for every transport.

Report the beneficiary’s diagnosis or condition that necessitated the ambulance transport(s).

Your cooperation in billing is appreciated. If you have any questions regarding this letter or require additional information, please do not hesitate to contact our office. You may do this either by telephone or in writing. The phone number is 1-877-567-9235. Written correspondence should be addressed to:

Empire Medicare Services

P.O. Box 69202

Harrisburg, PA 17106-9202

We will be more than happy to assist you with your Medicare Part B concerns.

Sincerely,

Jody B. Tay

Provider Reimbursement

Attachments

LOCALITY 11 FEE SCHEDULES Attachment I

Billing Method 1: Locality 11

January 1-June 30, 2001				July 1-December 31, 2001
CODE	75^th Percentile	50^th Percentile	IIC	CODE	75^th Percentile	50^th Percentile	IIC
A0426	404.06	404.06	N/A	A0426	411.93	411.93	N/A
A0427	404.06	404.06	N/A	A0427	411.93	411.93	N/A
A0428	153.37	153.37	153.37	A0428	156.36	156.36	156.36
A0429	282.43	256.75	153.37	A0429	287.93	261.75	156.36
A0433	404.06	404.06	N/A	A0433	411.93	411.93	N/A
A0434	404.06	404.06	N/A	A0434	411.93	411.93	N/A

Billing Method 2: Locality 11

January 1-June 30, 2001				July 1-December 31, 2001
CODE	75^th Percentile	50^th Percentile	IIC	CODE	75^th Percentile	50^th Percentile	IIC
A0426	404.06	404.06	N/A	A0426	411.93	411.93	N/A
A0427	404.06	404.06	N/A	A0427	411.93	411.93	N/A
A0428	333.78	148.92	153.37	A0428	340.28	151.82	156.36
A0429	308.10	282.43	153.37	A0429	314.10	287.93	156.36
A0433	404.06	404.06	N/A	A0433	411.93	411.93	N/A
A0434	404.06	404.06	N/A	A0434	411.93	411.93	N/A
A0380	8.22	8.22	5.82	A0380	8.38	8.38	5.94
A0390	10.27	10.27	8.90	A0390	10.47	10.47	9.08

Billing Method 3: Locality 11

January 1-June 30, 2001				July 1-December 31, 2001
CODE	75^th Percentile	50^th Percentile	IIC	CODE	75^th Percentile	50^th Percentile	IIC
A0426	397.07	397.07	N/A	A0426	404.81	404.81	N/A
A0427	397.07	397.07	N/A	A0427	404.81	404.81	N/A
A0428	149.11	149.11	149.11	A0428	152.01	152.01	152.01
A0429	149.11	149.11	149.11	A0429	152.01	152.01	152.01
A0433	397.07	397.07	N/A	A0433	404.81	404.81	N/A
A0434	397.07	397.07	N/A	A0434	404.81	404.81	N/A
A0382	35.95	26.70	N/A	A0382	36.65	27.22	N/A
A0422	77.03	61.62	37.11	A0422	78.53	62.82	37.83
A0424	133.51	128.38	N/A	A0424	136.11	130.88	N/A

Billing Method 4: Locality 11

January 1-June 30, 2001				July 1-December 31, 2001
CODE	75^th Percentile	50^th Percentile	IIC	CODE	75^th Percentile	50^th Percentile	IIC
A0426	693.23	477.56	473.26	A0426	706.73	486.86	482.48
A0427	949.98	949.98	955.13	A0427	968.48	968.48	973.73
A0428	282.43	256.75	149.11	A0428	287.93	261.75	152.01
A0429	301.94	256.75	149.11	A0429	307.82	261.75	152.01
A0433	949.98	949.98	955.13	A0433	968.48	968.48	973.73
A0434	949.98	949.98	955.13	A0434	968.48	968.48	973.73
A0380	8.22	8.22	5.82	A0380	8.38	8.38	5.94
A0390	10.27	10.27	8.90	A0390	10.47	10.47	9.08
A0382	35.95	26.70	N/A	A0382	36.65	27.22	N/A
A0422	77.03	61.62	37.11	A0422	78.53	62.82	37.83
A0424	133.51	128.38	N/A	A0424	136.11	130.88	N/A

LOCALITY 12 FEE SCHEDULES Attachment II

Billing Method 1: Locality 12

January 1-June 30, 2001				July 1- December 31, 2001
CODE	75^th Percentile	50^th Percentile	IIC	CODE	75^th Percentile	50^th Percentile	IIC
A0426	404.06	389.57	N/A	A0426	411.93	397.16	N/A
A0427	404.06	389.57	N/A	A0427	411.93	397.16	N/A
A0428	153.85	153.85	153.85	A0428	156.85	156.85	156.85
A0429	282.43	256.75	153.85	A0429	287.93	261.75	156.85
A0433	404.06	389.57	N/A	A0433	411.93	397.16	N/A
A0434	404.06	389.57	N/A	A0434	411.93	397.16	N/A

Billing Method 2: Locality 12

January 1-June 30, 2001				July 1-December 31, 2001
CODE	75^th Percentile	50^th Percentile	IIC	CODE	75^th Percentile	50^th Percentile	IIC
A0426	404.06	389.57	N/A	A0426	411.93	397.16	N/A
A0427	404.06	389.57	N/A	A0427	411.93	397.16	N/A
A0428	333.78	231.08	153.85	A0428	340.28	235.58	156.85
A0429	308.10	308.10	153.85	A0429	314.10	314.10	156.85
A0433	404.06	389.57	N/A	A0433	411.93	397.16	N/A
A0434	404.06	389.57	N/A	A0434	411.93	397.16	N/A
A0380	7.19	6.68	5.99	A0380	7.33	6.81	6.10
A0390	11.86	10.27	11.52	A0390	12.09	10.47	11.75

Billing Method 3: Locality 12

January 1-June 30, 2001				July 1-December 31, 2001
CODE	75^th Percentile	50^th Percentile	IIC	CODE	75^th Percentile	50^th Percentile	IIC
A0426	397.07	382.58	N/A	A0426	404.81	390.04	N/A
A0427	397.07	382.58	N/A	A0427	404.81	390.04	N/A
A0428	149.11	149.11	149.11	A0428	152.01	152.01	152.01
A0429	149.11	149.11	149.11	A0429	152.01	152.01	152.01
A0433	397.07	382.58	N/A	A0433	404.81	390.04	N/A
A0434	397.07	382.58	N/A	A0434	404.81	390.04	N/A
A0382	35.95	26.70	N/A	A0382	36.65	27.22	N/A
A0422	61.62	51.35	37.11	A0422	62.82	52.35	37.83
A0424	133.51	128.38	N/A	A0424	136.11	130.88	N/A

Billing Method 4: Locality 12

January 1-June 30, 2001				July 1-December 31, 2001
CODE	75^th Percentile	50^th Percentile	IIC	CODE	75^th Percentile	50^th Percentile	IIC
A0426	693.23	463.07	464.17	A0426	706.73	472.09	473.22
A0427	1435.75	935.49	1375.53	A0427	1463.71	953.71	1402.32
A0428	231.08	205.40	149.11	A0428	235.58	209.40	152.01
A0429	267.02	256.75	149.11	A0429	272.22	261.75	152.01
A0433	1435.75	935.49	1375.53	A0433	1463.71	953.71	1402.32
A0434	1435.75	935.49	1375.53	A0434	1463.71	953.71	1402.32
A0380	7.19	6.68	5.99	A0380	7.33	6.81	6.10
A0390	11.86	10.27	11.52	A0390	12.09	10.47	11.75
A0382	35.95	26.70	N/A	A0382	36.65	27.22	N/A
A0422	61.62	51.35	37.11	A0422	62.82	52.35	37.83
A0424	133.51	128.38	N/A	A0424	136.11	130.88	N/A

LOCALITY 13 FEE SCHEDULES Attachment III

Billing Method 1: Locality 13

January 1-June 30, 2001				July 1-December 31, 2001
CODE	75^th Percentile	50^th Percentile	IIC	CODE	75^th Percentile	50^th Percentile	IIC
A0426	450.27	388.65	N/A	A0426	459.04	396.22	N/A
A0427	450.27	388.65	N/A	A0427	459.04	396.22	N/A
A0428	156.08	156.08	156.08	A0428	159.12	159.12	159.12
A0429	359.45	354.32	156.08	A0429	366.45	361.22	159.12
A0433	450.27	388.65	N/A	A0433	459.04	396.22	N/A
A0434	450.27	388.65	N/A	A0434	459.04	396.22	N/A

Billing Method 2: Locality 13

January 1-June 30, 2001				July 1-December 31, 2001
CODE	75^th Percentile	50^th Percentile	IIC	CODE	75^th Percentile	50^th Percentile	IIC
A0426	450.27	388.65	N/A	A0426	459.04	396.22	N/A
A0427	450.27	388.65	N/A	A0427	459.04	396.22	N/A
A0428	333.78	333.78	156.08	A0428	340.28	340.28	159.12
A0429	333.78	308.10	156.08	A0429	340.28	314.10	159.12
A0433	450.27	388.65	N/A	A0433	459.04	396.22	N/A
A0434	450.27	388.65	N/A	A0434	459.04	396.22	N/A
A0380	6.93	6.16	5.99	A0380	7.07	6.28	6.10
A0390	6.93	6.93	11.52	A0390	7.07	7.07	11.75

Billing Method 3: Locality 13

January 1-June 30, 2001				July 1-December 31, 2001
CODE	75^th Percentile	50^th Percentile	IIC	CODE	75^th Percentile	50^th Percentile	IIC
A0426	443.28	381.66	N/A	A0426	451.92	389.10	N/A
A0427	443.28	381.66	N/A	A0427	451.92	389.10	N/A
A0428	149.11	149.11	149.11	A0428	152.01	152.01	152.01
A0429	149.11	149.11	149.11	A0429	152.01	152.01	152.01
A0433	443.28	381.66	N/A	A0433	451.92	389.10	N/A
A0434	443.28	381.66	N/A	A0434	451.92	389.10	N/A
A0382	26.70	26.70	N/A	A0382	27.22	27.22	N/A
A0422	84.21	61.62	38.83	A0422	85.85	62.82	39.59
A0424	133.51	128.38	N/A	A0424	136.11	130.88	N/A

Billing Method 4: Locality 13

January 1-June 30, 2001				July 1-December 31, 2001
CODE	75^th Percentile	50^th Percentile	IIC	CODE	75^th Percentile	50^th Percentile	IIC
A0426	739.44	462.15	473.26	A0426	753.84	471.15	482.48
A0427	1481.96	934.57	1384.62	A0427	1510.82	952.77	1411.58
A0428	267.02	256.75	149.11	A0428	272.22	261.75	152.01
A0429	333.78	251.62	149.11	A0429	340.28	256.52	152.01
A0433	1481.96	934.57	1384.62	A0433	1510.82	952.77	1411.58
A0434	1481.96	934.57	1384.62	A0434	1510.82	952.77	1411.58
A0380	6.93	6.16	5.99	A0380	7.07	6.28	6.10
A0390	6.93	6.93	11.52	A0390	7.07	7.07	11.75
A0382	26.70	26.70	N/A	A0382	27.22	27.22	N/A
A0422	84.21	61.62	38.83	A0422	85.85	62.82	39.59
A0424	133.51	128.38	N/A	A0424	136.11	130.88	N/A