Below is a comprehensive list of forms needed to complete a BLS routine ambulance transfer in the State of Connecticut. More medical information and demographics are necessary but in regards to forms, this it…
None of the information below should be construed as legal advice. If there are questions always consult the proper authority.
Medical Necessity Form (aka Physician’s Certification Statement (PCS) or MNF): An MNF is required on routine, non-emergency transports where the patient has Medicare as their primary insurance. The form essentially works as a prescription for ambulance transport. Medicare never pays for wheelchair van transport so this form represents the threshold between van and ambulance. There are some types of transports from skilled nursing facilities (SNF) and hospital where the sending facility is required to pay for the transport and therefore will not issue or sign an MNF.
The rules around the use of an MNF and meeting Medicare’s medical necessity requirements are extensive and cannot be captured adequately here. Aetna and ASM crews are trained, reviewed, remediated and subject to a rigorous quality assurance process in this regard.
Physician’s Emergency Certificate (PEC): A PEC is required for the ambulance transport of a psychiatric patient going to any destination (typically a locked behavioral health unit) against their will. A PEC must be an original form, typically demonstrated by being two-sided and often written in blue ink for this purpose. A copy cannot be used and it must be signed by a physician. It must accompany the patient and therefore cannot be faxed or emailed ahead as facilities will not accept a copy. This form is NOT used for voluntary patients or patients who are conserved where the conservator has ordered transport.
This form also authorizes the ambulance crew to hold the patient against their will. In Connecticut, the only forms that allow an ambulance crew to hold a patient against their will are a PEC and an Emergency Examination Report issued by a licensed clinical social worker or a police officer.
Transportation Authorization Certificate: A TAC compels the State of Connecticut to pay for the transportation of a patient in need of psychiatric care who is being admitted to an inpatient, state-operated facility. The receiving facility representative signs on Line 4 of this form and it is used as a check and balance before issuing payment to a transportation provider.
There are only five state-operated, inpatient psychiatric facilities in the state, Blue Hills, Cedarcrest, Connecticut Valley Hospital (CVH), Greater Bridgeport Mental Health and Capitol Region Mental Health Center. An ambulance crew does NOT need this form if the destination is any other facility. The need for this form is not created by any other factor such as the chief complaint, the payor or the sending location.
W-10 (demographic portion of the discharge summary): Hospitals are required to provide the ambulance provider with enough information to safely complete the ambulance transport. Aetna and ASM are HIPAA Covered Entities and all employees have been trained in appropriately handling protected health information (PHI). A hospital can restrict the information they issue as long as the transport can be safely completed and sufficient information has been provided to carry out treatment, payment and healthcare operations.
Hospitals are no longer required to provide a State of Connecticut W-10 form or a full discharge summary and quite often they send the summary electronically to the SNF. Although the W-10 format is not mandated, hospitals must provide demographics, history, meds, allergies and any other pertinent information even if the patient is returning to a private residence without scheduled services.
No other form is required for routine BLS ambulance transport. Ambulance crews should NOT be looking for a full discharge summary, so-called “No Harm” letters, full medication administration logs (MARS), psychiatric notes, or any other form that is not listed above.
Questions? Call the billing office at (860) 647-9798.