The Ambulance section displays information about the ambulance relating to the claim. Certification information at the claim level applies to all service lines of the claim, unless overridden by certification information at the service line level. This information is required on all claims involving ambulance transport services.
The Ambulance fields are defined by section below:
Transport Reason CodeTransport Reason Code
Code indicating the reason for ambulance transport. Options are:
| A | Patient was transported to nearest facility for care of symptoms, complaints, or both. |
| B | Patient was transported for the benefit of a preferred physician. |
| C | Patient was transported for the nearness of family members. |
| D | Patient was transported for the care of a specialist or for availability of specialized equipment. |
| E | Patient transferred to rehabilitation facility. |
The weight of the patient at the time of transport.
The distance traveled during the transport of the patient.
Purpose of Round TripPurpose of Round Trip
A free-form description to clarify the purpose for the round trip ambulance service.
Purpose of Stretcher Purpose of Stretcher
A free-form description to clarify the purpose for the use of a stretcher during ambulance service. Required if needed to justify use of a stretcher.
Condition CodesCondition Codes
Code(s) used to identify condition(s) relating to this bill or relating to the patient. Mark the check boxes for all the applicable condition codes.
Pick-Up Location: This section is used to specify the geographic location of the named party. If the ambulance pick-up location is in an area where there are no street addresses, enter a description of where the service was rendered. This information is required when billing for ambulance or non-emergency transportation services.
Address Line 1 & 2Address Line 1 & 2
Ambulance pick-up address.
Ambulance pick-up postal zone zip code.
Ambulance pick-up city name.
Ambulance pick-up state or province code.
Ambulance pick-up country code.
Subdivision CodeSubdivision Code
Ambulance pick-up country subdivision code.
Drop-Off Location: This section is used to specify the geographic location of the named party. If the ambulance pick-up location is in an area where there are no street addresses, enter a description of where the service was rendered. This information is required when billing for ambulance or non-emergency transportation services.
Individual last name or organization name of ambulance drop-off location.
Address Line 1 & 2Address Line 1 & 2
Ambulance drop-off address.
Ambulance drop-off postal zone zip code.
Ambulance drop-off city name.
Ambulance drop-off state or province code.
Ambulance drop-off country code.
Subdivision CodeSubdivision Code
Ambulance drop-off country subdivision code.
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