NOTICE OF POTENTIAL PATIENT PAYMENT FOR AMBULANCE SERVICES

Insurance, Medicare, and Medicaid Coverage Information

 

Important: This notice explains that you may owe a deductible, coinsurance, copayment, or other amount for ambulance services. This is an estimate and does not guarantee coverage or payment. Your final responsibility will be determined after Medicare, Medicaid, your Medicare Advantage plan, and/or other insurance processes the claim.

 

Why You May Owe an Amount

• Medicare or Medicaid determines that the trip was not covered, not medically necessary, or did not meet transportation requirements.

• The transport was beyond the nearest appropriate medical facility, and the additional distance is not covered.

• Your deductible, coinsurance, copayment, spend-down, or other permitted cost-sharing applies.

• Your eligibility or coverage was inactive on the date of service, required authorization was not obtained, or the service was outside your plan’s network or benefit rules.

• Another insurer is responsible for payment, or additional information is needed before the claim can be processed.

 

Your Rights and Next Steps

• Ask Spirit EMS to explain the expected charge and why coverage may be limited.

• Keep this notice and review your Medicare Summary Notice, Explanation of Benefits, or Medicaid notice after the claim is processed.

• If coverage is denied, follow the appeal instructions in the notice from Medicare, Medicaid, or your health plan.

• Provide current insurance information and any requested medical or authorization records promptly.