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Clarification of Requirements for Medical Transportation Emergency Statement

November 1, 2016

When completing the emergency statement for air or ground medical transportation, providers must include the name of the hospital to which a recipient was transported. This information must be included in the Additional Claim Information field (Box 19) of the CMS-1500 claim form or the Remarks field (Box 80) of the UB-04 claim form, or on an attachment. Claims submitted with an acronym in place of a hospital name (for example, VMC) will be denied. Abbreviations are acceptable (for example Valley Med. Ctr.).

Providers are reminded that on the emergency statement the physician accepting responsibility for the recipient must be either a Doctor of Medicine (M.D.) or a Doctor of Osteopathic Medicine (D.O.). A physician signature is not required.

Additional information and provider manual updates regarding this issue will publish in a future Medi-Cal Update.