Claims that have been denied typically are denied for one of two reasons: 1) Use of the ambulance
was determined by the carrier to not be medically necessary; or 2) ambulance service is not a covered
service.
If a claim has been determined not to have been medically necessary, there are some specific things
that you can do. Many carriers have a review process in which previously denied claims can be
resubmitted, with additional information, for further consideration. This additional information
involves obtaining additional medical information from the physician, which is your
responsibility, in order to make a determination that the use of an ambulance was medically necessary.
The information must be very specific in nature - a doctor writing a letter stating that "ambulance
service was medically necessary" will normally be denied on review. If the claim has been denied as
"not medically necessary" because the physician did not submit a CMN within the required
twenty-one (21) days, there is no appeal process available under HCFA rules. The patient needs to contact
their physician and determine why the physician failure to provide a CMN within the required time frame in
accordance with Federal Rules and Regulations.