Welcome to the Department of Health Care Services Welcome to Medi-Cal Welcome to the Department of Health Care Services

HIPAA: Ground Ambulance Mileage Electronic Billing Clarification

HIPAA Transactions July 14, 2006

Existing policy requires providers to include complete origination and destination addresses when submitting claims for ground ambulance mileage (HCPCS code X0034 or X0216). When billing these services in the Professional ASC X12N 837 v.4010A1 transaction format, the origination and destination may be conveyed one of two ways:

  1. As origination and destination information (or other policy requirements) text length may exceed the NTE02 Claim Note byte limitation (Loop 2300), submitters are encouraged to also use the Claim Line NTE02 (Loop 2400) to convey the address information.
  2. If the byte limitation of these two segments combined is still insufficient to convey the policy information, submitters are encouraged to utilize the PWK segment and link a paper or fax attachment to the claim.

The second option necessitates an Attachment Control Form (ACF), which is used as a coversheet for the supporting paper or fax attachments. The ACF has a pre-printed Attachment Control Number (ACN) that submitters input on their electronic claim submission in the PWK segment.

Providers mailing or faxing attachments for electronic claims must enter the pre-printed ACN on the electronic claim and include the ACF with the attachments sent in the mail or by fax. ACF supplies can be ordered by calling the Telephone Service Center (TSC) at 1-800-541-5555.

Effective July 14, 2006 after 6 p.m., Medi-Cal will implement a third means to convey the origination and destination address information required for ground ambulance mileage billing:

  • The origination address may be conveyed in Loop 2310D. If multiple services lines have different procedure modifiers, such as when indicating a multiple leg trip, then the origin location will be in Loop 2420C of the service line used for the previous leg of the trip (i.e. the destination of leg #1 is also the origin of leg #2). For the NM1 (Service Facility Location) qualifier, a code ‘77’ will need to be entered along with the new field information containing the provider name, address 1, address 2 (optional), the city, state, and ZIP code.
  • The destination address may be conveyed in Loop 2420C. The location specified in each occurrence of this loop indicates the destination consistent with the procedure modifier in SV101-3. For the NM1 (Service Facility Location) qualifier, a code ‘77’ will need to be entered along with new field information containing the provider name, address 1, address 2 (optional), city, state, and ZIP code.

Please note that the maximum number of addresses that can be submitted is six.

The 837 Version 4010A1 Health Care Claim Companion Guide has been updated to reflect this change with this implementation.

For additional billing guidance, refer to the 837 Version 4010A1 Health Care Claim Companion Guide on the ASC X12N Version 4010A1 Companion Guides and NCPDP Technical Specifications page of the Medi-Cal Web site. If you have further questions, call the TSC at 1-800-541-5555, then select Option 16 followed by Option 11 for Computer Media Claims (CMC). Software vendors and out-of-state billers/submitters who bill for in-state providers should call (916) 636-1200, and then select the appropriate prompt.