Alberta.ca » Income and Employment Supports Policy Manual


Health Benefits Card Coverage

Published Date: January 01, 2015
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02 Ambulance Services

ISTHB Regulation, Section 73(2)(e) provides for coverage of ambulance services.

INTENT

To provide coverage for emergency ground ambulance transportation to the nearest hospital where essential medical care can be given, and no other insurance or government department is responsible for coverage.

POLICY

Eligibility
Alberta Community and Social Services provides payment for ambulance services under the following circumstances:

  • In an emergency and
  • Services were provided in the province of Alberta and
  • File status was active for the benefit period in which the ambulance service was provided and
  • The client was listed on the health benefits card or an EMP 0018 Purchase Authorization and Invoice (Voucher) was issued and
  • No other insurance or government department is responsible for coverage (e.g., Health Canada, Solicitor General, employer’s coverage, auto insurance in cases of motor vehicle accident)


Exclusions Policy
Community and Social Services does not pay for transporting a patient from one hospital to another. If someone has been brought by ambulance to a hospital emergency room but cannot be treated there, and is being moved by ambulance to another hospital for emergency treatment, the Alberta Health Care Insurance Plan pays for the ambulance.

Community and Social Services only covers the cost to the nearest hospital that can provide the service required. If a client makes a request to go to a more distant hospital, the cost of travel is not covered by Community and Social Services.

Community and Social Services does not pay for:

  • Full amounts for each client in instances where multiple patients are being transported by ambulance. A base rate is payable for each patient, and kilometers are split by the number of patients that are being transported.
  • Any supplies related to ambulance services given to a client.
  • Ambulance billing when a client has insurance that will cover the entire cost. If the ambulance bill exceeds the client’s insurance coverage, Community and Social Services will pay the difference, including the deductible, up to the maximum rate set by Non-Insured Health Benefits program.
  • Ambulance services for persons in the custody of the Solicitor General’s Department at the time the ambulance service was required.
  • Air ambulance service. The AHCIP pays for air ambulance service and pays the ground escort fee for air ambulance service.
  • Any amount above the rates established in the rate schedule set by Alberta Health for government health benefits programs.
  • An ambulance to take someone home from hospital, or to take someone to any destination other than a hospital.


Exception

An Income Support Specialist may authorize, for Client Type (CT) 43 only, an ambulance to take someone home from hospital, if medically required.

Allowable Ambulance Charges

An ambulance authority charges a flat fee for responding and providing emergency services, even if the patient is not transported to a hospital after their condition is stabilized. Alberta Community and Social Services pays this fee. An ambulance authority is not paid if no service was provided (e.g., prank call, third-party call for services, no service needed).

In addition to the responding charge, other allowable ambulance costs are kilometres and waiting time. Rates are paid in accordance with the rate schedule established by Alberta Health for government health benefits programs.

Suspected Abuse of Ambulance Service

ABC will carry out, on behalf of Community and Social Services, audits of individual ambulance operators to ensure compliance with Community and Social Services policy and service expectations. ABC will generate reports to Financial Operations when irregularities occur. Financial Operations will notify individual worksites when abuse of ambulance benefits by a client is suspected.

It is the responsibility of the worker to investigate suspected cases of ambulance abuse. When abuse of ambulance service is determined, the worker contacts the client to discuss the concerns related to the abuse and then gives a warning that an overpayment will be assessed if further abuse occurs. If abuse continues (confirmed by ambulance authority or hospital), the worker sets up a debt in the Recoveries System for the amount to be recovered.

Health Benefits Exception Committee

Decisions regarding ambulance services provided as a Community and Social Services health benefit are defined in Regulation as decisions of the Minister, and therefore, an appeal panel does not have authority to overturn a decision regarding health benefits provided under Part 2 Division 2 of the IESA and ISTHB Regulation, Section 73.

Clients requesting ambulance services beyond those covered by Community and Social Services may ask for a review of the decision by the Health Benefits Exception Committee.

PROCEDURES

Payment Method
Alberta Blue Cross (ABC) on behalf of  Community and Social Services administers, controls and pays ambulance services provided within the province of Alberta to all Community and Social Services clients with a valid Community and Social Services health benefits card.

Ambulance authorities send their claim forms to:

Alberta Blue Cross
10009 – 108 street
Edmonton, AB   T5J 3C5

Fax: 780-498-8883

It is the responsibility of the ambulance operator to provide ABC with all relevant information necessary for payment.

An EMP 0018 Purchase Authorization and Invoice (Voucher) is only used for the following circumstances:

  • If a Health Benefits Card has not yet been issued or a dependant was added to the file after the card was issued and the service is urgently required before the next card is received.
  • For One-Time Issue recipients (client sub-type 81 and 82).


The EMP 0018 Purchase Authorization and Invoice:

  • Is issued to the ambulance authority
  • Is forwarded by the ambulance authority to Alberta Blue Cross for payment, 
  • Has no dollar amount, 
  • Is used only for ambulance services outlined in policy, or approved by the Health Benefits Exception Committee.


Service Description for Ambulance Services

The appropriate Goods Code, Need Code and Description for ambulance services must be included on the EMP 0018 Purchase Authorization and Invoice. The period in the description must be the same as the Period of Assistance on the EMP 0018 Purchase Authorization and Invoice, and must cover the dates of service on the vendor’s claim form.