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The purpose of this bulletin is to inform Emergency Ambulance Transport providers that DMAS and all contracted Managed Care Organizations (MCOs) will reimburse an originating site fee for facilitating a telemedicine consultation between a Medicaid member and a Medicaid-enrolled provider for the purposes of identifying whether the Medicaid member is in need of emergency ambulance transportation. Specifically, emergency ambulance transportation providers may submit a claim for providing a telemedicine “originating site fee” service (CPT Q3014) under the following conditions:

• The Emergency Ambulance Transport provider is licensed as a Virginia Emergency Medical Services (EMS) ambulance provider.
• The Emergency Ambulance Transport provider must be enrolled as such with DMAS.
• The Medicaid member is in a physical location where telemedicine services can be received per requirements set forth in the Telehealth Supplement.
• The member and provider of telemedicine services are not in the same physical location during the consultation.
• The Emergency Ambulance Transport provider assists with initiation of the visit but the presence of the Emergency Ambulance Transportation provider in the actual visit shall be determined by a balance of clinical need and member preference or desire for confidentiality.

Emergency Ambulance Transport providers should submit a claim for providing an originating site fee service in one of two ways:

• If the Member receives emergency ambulance transportation subsequent to and based on the facilitated telemedicine consultation, submit two claims: one claim for Q3014 on a CMS-1500 and a separate claim for emergency transportation services.
• If the Member does not receive emergency ambulance transportation subsequent to and based on the facilitated telemedicine consultation, submit one claim for Q3014 on a CMS-1500.

Emergency Ambulance Transport providers should maintain the Pre-hospital Patient Care Report (PPCR) documentation that includes identifying information of the Provider of telemedicine services (e.g., NPI), evidence that emergency transportation was or was not recommended by the telemedicine provider, and whether the member did or did not receive emergency ambulance transportation services subsequent to and based on the facilitated telemedicine consultation.

Note that service limitations applicable to all provider types eligible to bill for Q3014 also apply to Emergency Ambulance Transport providers (e.g., one unit per day per provider per member).

For questions on coverage for members enrolled in a managed care organization, refer to the contact information listed below.