Medicare “Locality” Rule & ALS Assessment
“Locality” Rule – MAC Discretion – Since the inception of the CMS Internet Only Manual (in 2003), the Benefit Policy Manual 100-02, Chapter 10, section 10.3.5 has always defined “Locality” as:
The term “Locality” with respect to ambulance service means the service area surrounding the institution to which individuals normally travel or are expected to travel to receive hospital or skilled nursing services.
An example is then listed to indicate that the ambulance transportation to either of two large metropolitan hospitals that regularly provide services to the small community where the emergency arose would be covered destinations.
On June 16, 2017, CMS issued Transmittal 236 to add the following at the end of the paragraph before the example:
The MAC’s have the discretion to define locality in their service areas.
Effectively, there is no change as Carriers and Intermediaries (now MACs) have always had discretion to determine the “locality” around each facility. Often, they did this with mileage edits, e.g. in an urban area, they may have set a parameter of 15 miles, but in a rural area, they have allowed a much larger area. Nevertheless, it is a good time to ask your MAC for their definitions of the localities in their service area or the mileage edits that they use.
A copy of the Transmittal can be obtained at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R236BP.pdf
The same Transmittal made two changes to the CMS definition of “ALS Assessment”, as listed in the Benefit Policy Manual, 100-02, Chapter 10, section 30.1.1, as follows:
1. Assuming the ALS assessment is performed and meets the definition, this section now states that the services provided by the supplier or provider “shall” be covered at the ALS emergency level. Previously, the definition indicated the services “may” be covered at the ALS emergency level. This change was needed as some MACs thought they did not have to pay ALS emergency when the ALS assessment is performed in accordance with the definition.
2. The other change was to add to the end of the paragraph “and all other coverage requirements are met”. In other words, aside from providing the ALS assessment in accordance with the definition, there must also be ambulance transportation, the origin/destination requirements are met, the provider/supplier must meet all vehicle and crew requirements, transportation was medically necessary, the ALS assessment was medically necessary, etc.
The effective date for the changes noted above is September 18, 2017.