The final regulation to establish an ambulance fee schedule contained an additional provision that clarified the payment policy for pricing a single ambulance vehicle transport of a Medicare beneficiary where more than one patient is onboard the ambulance. The following payment policy was implemented on October 30, 2002.

   1.   When more than one patient is transported in an ambulance, the
        Medicare allowed charge for each beneficiary is a percentage of the
        allowed charge for a single beneficiary transport (the "allowed
        charge" for a single beneficiary transport is the lower of the
        submitted charge and the fee schedule amount for the service ­ which,
        during the fee schedule transition period, is a blended amount.) The
        applicable percentage is based on the total number of patients
        transported, including both Medicare beneficiaries and non-Medicare
        patients.

   2.   This policy applies to both ground and air transports. The term
        "ground transport" includes transports by water ambulance.

   3.   If two patients are transported at the same time in one ambulance to
        the same destination, the adjusted payment allowance for each
        Medicare beneficiary would equal 75 percent of the single-patient
        allowed amount applicable to the level of service furnished a
        beneficiary, plus 50 percent of the total mileage payment allowance
        for the entire trip.

        If three or more patients are transported at the same time in one
        ambulance to the same destination, the adjusted payment for each
        Medicare beneficiary would equal 60 percent of the single-patient
        allowed amount applicable to the level of service furnished that
        beneficiary plus a proportional mileage allowed amount, i.e., the
        total mileage allowed amount divided by the number of all the
        patients onboard.

   4.   The fact that the level of medically necessary service among the
        patients may be different is not relevant to this payment policy. The
        percentage is applied to the allowed amount applicable to the level
        of service that is medically necessary for each beneficiary.

   5.   If a multi-patient transport includes multiple destinations, then the
        Medicare allowed amount for mileage depends upon whether it is for an
        emergency versus non-emergency ground transport.

        a.   For an emergency ground transport, which includes basic life
             support emergency (BLS-E), advanced life support, level 1
             emergency (ALS1-E), advanced life support, level 2 (ALS2), and
             special care transport (SCT), the mileage payment shall be based
             on the number of miles to the nearest appropriate facility for
             each patient, divided by the number of patients on board when
             the vehicle arrives at the facility. This formula applies
             cumulatively for beneficiaries who are the 2nd or 3rd patient to
             be delivered.

        b.   For a non-emergency ground transport, which includes BLS and
             ALS1, the mileage payment shall be based on the number of miles
             from the point-of-pickup to the nearest appropriate facility for
             each beneficiary, divided by the number of beneficiaries on
             board at the point-of- pickup. This formula applies cumulatively
             for beneficiaries for multiple points-of-pickup. Mileage other
             than the mileage that would be incurred by transporting the
             beneficiary directly from the point-of-pickup to the nearest
             appropriate facility is not covered. Thus, for non- emergency
             transports, the extra mileage that may be incurred by having
             multi-destinations shall not be taken into account.

        c.   For air transports, the policy is the same as for emergency
             ground transports.

   6.   If a Medicare beneficiary is furnished medically necessary supplies,
        and the supplier bills supplies separately, then the allowed amount
        of the supplies is not subject to an apportionment for multiple
        patients. The allowed amount for supplies should be determined in the
        same manner as if the beneficiary was the only patient on board the
        vehicle.

   1.   Suppliers should use modifier GM to identify a multiple transport.

   2.   Suppliers are required to submit documentation to specify the
        particulars of a multiple transport. The documentation must include
        the total number of patients transported in the vehicle at the same
        time and the Health Insurance Claim (HIC) numbers for each Medicare
        beneficiary.

   3.   Suppliers are required to submit the charge applicable to the
        appropriate service rendered to each beneficiary and the total
        mileage for the trip.

   4.   Suppliers are required to submit all associated Medicare claims for
        that multiple transport within a reasonable number of days of
        submitting the first claim.

   5.   If there is only one Medicare beneficiary in the multiple patient
        transport, the claims will be processed using the necessary
        information from the supplier's documentation.

   6.   If more than one Medicare beneficiary is transported in a multiple
        patient transport, then the carrier must associate all ambulance
        claims for Medicare beneficiaries for the one transport.

   7.   The Medicare carrier must process the claims and apply the correct
        percentages to the allowed amount applicable to the level of service
        furnished and mileage.

        a.   When two patients are transported, for each beneficiary, the
             Medicare carrier will:

             i.   Allow 75 percent of the allowed amount for a single-person
                  transport (excluding separately billable mileage).

             ii.  For mileage to a single destination, allow half of the
                  total mileage.

             iii. For mileage for both emergency ground transports and all
                  air transports to multiple destinations, the allowed amount
                  for the first leg is the amount for the mileage divided by
                  2. The allowed amount for the second leg is the full
                  mileage. Thus, payment on behalf of a beneficiary whose
                  transport is to the first nearest appropriate facility is
                  based on half the mileage amount to that facility, whereas
                  payment on behalf of the second beneficiary, whose
                  transport was to the next nearest appropriate facility,
                  would be based on half of the mileage to the first facility
                  plus all of the mileage from the first facility to the
                  second facility.

             iv.  For mileage for non-emergency ground transports, allow only
                  the mileage from the point-of-pickup to the nearest
                  appropriate facility and then divide that amount by the
                  number of beneficiaries loaded on board at the
                  point-of-pickup. Mileage other than the mileage that would
                  be incurred by transporting the beneficiary directly from
                  the point-of-pickup to the nearest appropriate facility is
                  not covered.

        b.   When three or more patients are transported, for each
             beneficiary, the Medicare carrier will:

             i.   Allow 60 percent of the allowed amount for a single-person
                  transport (excluding separately billable mileage).

             ii.  For mileage to a single destination, allow a pro rata share
                  of the total mileage.

             iii. For mileage for both emergency ground transports and all
                  air transports to multiple destinations, the allowed amount
                  for each leg of the transport is a pro rata share of the
                  total mileage based on the number of patients on board upon
                  arrival at each destination.

             iv.  For mileage for non-emergency ground transports, the
                  allowed amount for each beneficiary is based on the mileage
                  to the nearest appropriate facility divided by the number
                  of beneficiaries loaded on board at the point-of-pickup
                  (including any intermediate points-of-pickup). Medicare
                  will not take into account any mileage other than the
                  mileage that would be incurred from transporting each
                  beneficiary directly from the point- of-pickup to the
                  nearest appropriate facility.

   8.   The following appropriate message codes will be used to indicate that
        there is a reduction: M16 ­ "Please see the letter or bulletin of
        (date) for further information;" N45 ­ "Payment based on authorized
        amount."