AMBULANCE MAXIMUM ALLOWABLE FEE SCHEDULE THIS IS YOUR WISCONSIN MEDICAID MAXIMUM ALLOWABLE FEE SCHEDULE, WHICH IS IN EFFECT AS OF THE DATE OF THIS REPORT. WISCONSIN MEDICAID CERTIFIED PROVIDERS WILL BE REIMBURSED FOR SERVICES PROVIDED TO PROGRAM RECIPIENTS AT THE LOWER OF THEIR USUAL AND CUSTOMARY CHARGE, OR THE MAXIMUM ALLOWABLE FEE. SERVICES REIMBURSED BASED ON PROVIDER SPECIFIC (CONTRACTED RATES) AND REGIONAL OR SPECIALTY BASED RATES ARE NOT INCLUDED IN THIS FEE SCHEDULE. NOTE: BADGERCARE PLUS BENCHMARK PLAN MEMBERS WILL BE RESPONSIBLE FOR A $50.00 COPAYMENT PER TRIP. ALTHOUGH THE FEE SCHEDULE DOES NOT ADDRESS THE VARIOUS COVERAGE LIMITATIONS ROUTINELY APPLIED BY WISCONSIN MEDICAID BEFORE FINAL PAYMENT IS DETERMINED (E.G., RECIPIENT AND PROVIDER ELIGIBILITY, BILLING INSTRUCTIONS, FREQUENCY OF SERVICES, THIRD PARTY LIABILITY, COPAYMENT, AGE RESTRICTIONS, PRIOR AUTHORIZATION, ETC.), IT DOES CONTAIN THE FOLLOWING INFORMATION: PROC/M1/M2/TM PROC - THE PROCEDURE CODE RECOGNIZED BY WISCONSIN MEDICAID TO IDENTIFY THE SERVICE PROVIDED. M1/M2 - ONE OR TWO APPLICABLE MODIFIER(S) AFFECTING REIMBURSEMENT AMOUNT. TM - DESCRIPTIVE MODIFIER USED TO CONVEY INFORMATION FORMERLY CONVEYED BY TOS. NOTE: IN CERTAIN INSTANCES THE MODIFIER LISTED IS BEING USED BOTH TO CONVEY INFORMATION FORMERLY CONVEYED BY TOS AND TO AFFECT THE REIMBURSEMENT AMOUNT. IN THESE INSTANCES THE MODIFIER WILL BE DISPLAYED TWICE, ONCE IN THE M1 OR M2 COLUMN AND ONCE IN THE TM COLUMN, EVEN THOUGH IT WILL ONLY BE BILLED ONCE ON THE CLAIM DETAIL. DESCRIPTION - AN ABBREVIATED DESCRIPTION OF THE PROCEDURE CODE PROVIDER TYPE - ALL APPLICABLE PERFORMING PROVIDER TYPES FOR THE PROCEDURE CODE. SEE TABLE I FOR A LISTING OF PROVIDER TYPES APPLICABLE TO THIS SCHEDULE. PAC - THE PRICING ACTION CODE IDENTIFIES NON-COVERED SERVICES OR THE SOURCE AND METHOD OF PRICING THE PROCEDURE (REFER TO TABLE II). EFFECT DATE - THE EFFECTIVE DATE OF SERVICE ON OR AFTER WHICH THE MAXIMUM ALLOWABLE FEE APPLIES. MAX FEE - MAXIMUM ALLOWABLE FEES FOR THE PROCEDURE CODES LISTED. IF A MAX FEE IS NOT INDICATED, USE THE PAC AND TABLE II TO DETERMINE THE REASON (E.G., PAC 220 INDICATES SERVICE NOT COVERED; PAC 21J INDICATES INDIVIDUAL CONSIDERATION, ETC.). THIS INFORMATION IS INTENDED TO HELP YOU UNDERSTAND THE WISCONSIN MEDICAID MAXIMUM ALLOWABLE FEE SCHEDULE. IF YOU HAVE QUESTIONS, PLEASE CONTACT WISCONSIN MEDICAID PROVIDER SERVICES AT: (608) 221-9883 OR (800) 947-9627* *WHEN REQUESTING INFORMATION, PLEASE BE SPECIFIC AS TO WHICH PROVIDER TYPE YOU ARE REFERRING (I.E. AMBULANCE). TABLE I PROVIDER TYPES 25 – AMBULANCE TABLE II PRICING ACTION CODES (PAC) 21J,11J - INDIVIDUAL CONSIDERATION, MEDICAL CONSULTANT 220,120 - NON-COVERED SERVICE, NOT A WISCONSIN MEDICAID BENEFIT 270,170 - PAID AT THE LOWER OF THE BILLED AMOUNT OR MAXIMUM ALLOWABLE FEE ACCORDING TO PROVIDER TYPE TABLE III MODIFIERS MODIFIER DESCRIPTION -------------- ------------------------------------------------------------------------------------ GM MULTIPLE PATIENTS ON ONE AMBULANCE TRIP PROC DESCRIPTION PROC M1 M2 TM PROVIDER TYPE PAC EFFECT MAX FEE DATE A0225 AMBULANCE SERVICE, NEONATAL TRANSPORT, BASE RATE, EMERGENCY TRANSPORT, ONE WAY A0225 25 270 10/01/03 305.37 A0382 BLS ROUTINE DISPOSABLE SUPPLIES A0382 25 270 10/01/03 14.58 A0384 BLS SPECIALIZED SERVICE DISPOSABLE SUPPLIEDEFIBRILLATION (TO BE USED ONLY IN JURISDICTIO A0384 25 270 10/01/03 14.58 A0392 ALS SPECIAL SERVICE DISPOSE SUPPLIES, DEFIB (USED IN JURISDIC WHERE DEFIB CANNOT BE BLS) A0392 25 270 10/01/03 30.00 A0394 ALS SPECIALIZED SERVICE DISPOSABLE SUPPLIEIV DRUG THERAPY A0394 25 270 10/01/03 25.00 A0396 ALS SPECIALIZED SERVICE DISPOSABLE SUPPLIES, ESOPHAGEAL INTUBATION A0396 25 270 10/01/03 25.00 A0398 ALS ROUTINE DISPOSABLE SUPPLIES A0398 25 270 10/01/03 14.58 A0420 AMBULANCE WAITING TIME (ALS OR BLS), ONE HALF (1/2) HOUR INCREMENTS A0420 25 270 10/01/03 22.80 A0422 AMBULANCE (ALS OR BLS) OXYGEN AND OXYGEN SUPPLIES, LIFE SUSTAINING SITUATION A0422 25 270 10/01/03 14.58 A0424 EXTRA AMBULANCE ATTENDANT, GROUND (ALS OR BLS) OR AIR; (REQUIRES MEDICAL REVIEW) A0424 25 270 10/01/03 22.80 A0425 GROUND MILEAGE, PER STATUTE MILE A0425 25 270 10/01/03 5.50 A0425 GM 25 270 10/01/03 2.75 A0426 AMBULANCE SERVICE, ADVANCED LIFE SUPPORT, NON-EMERGENCY TRANSPORT, LEVEL 1 (ALS1) A0426 25 170 10/01/03 112.75 A0426 GM 25 170 10/01/03 56.38 A0427 AMBULANCE SERVICE, ADVANCED LIFE SUPPORT, EMERGENCY TRANSPORT, LEVEL 1 (ALS1-EMERGENCY) A0427 25 270 10/01/03 178.52 A0427 GM 25 270 10/01/03 89.26 A0428 AMBULANCE SERVICE, BASIC LIFE SUPPORT, NON-EMERGENCY TRANSPORT, (BLS) A0428 25 170 10/01/03 93.96 A0428 GM 25 170 10/01/03 46.98 A0429 AMBULANCE SERVICE, BASIC LIFE SUPPORT, EMERGENCY TRANSPORT (BLS-EMERGENCY) A0429 25 170 10/01/03 150.34 A0429 GM 25 170 10/01/03 75.17 A0430 AMBULANCE SERVICE, CONVENTIONAL AIR SERVICES, TRANSPORT, ONE WAY (FIXED WING) A0430 25 270 10/01/03 2232.34 A0430 GM 25 270 10/01/03 1116.17 A0431 AMBULANCE SERVICE, CONVENTIONAL AIR SERVICES, TRANSPORT, ONE WAY (ROTARY WING) A0431 25 170 10/01/03 2595.43 A0431 GM 25 170 10/01/03 1297.72 A0433 ADVANCED LIFE SUPPORT, LEVE 2 (ALS 2) A0433 25 170 10/01/03 258.39 A0433 GM 25 170 10/01/03 129.20 A0434 SPECIALTY CARE TRANSPORT (SCT) A0434 25 170 10/01/03 305.37 A0434 GM 25 170 10/01/03 152.69 A0435 FIXED WING AIR MILEAGE, PER STATUTUE MILE A0435 25 170 10/01/03 6.57 A0435 GM 25 170 10/01/03 3.29 A0436 ROTARY WING AIR MILEAGE, PER STATUTE MILE A0436 25 170 10/01/03 17.51 A0436 GM 25 170 10/01/03 8.76 A0998 AMBULANCE RESPONSE AND TREATMENT, NO TRANSPORT A0998 25 270 01/01/06 68.32 A0999 UNLISTED AMBULANCE SERVICE A0999 25 270 10/01/03 20.00 S0207 PARAMEDIC INTERCEPT, NON-HOSPITAL-BASED ALS (NON-VOLUNTARY), NON-TRANSPORT S0207 25 220 01/01/03 END OF REPORT