DRAFT Schedule Ambulance_Ground SFVAHCS.pdf

AMBULANCE (Ground)

SCHEDULE OF SERVICES – PRICE SCHEDULE

BASE PERIOD:

Line Item

Description of Services

12-Month Quantity

(Estimated Maximum)

Unit of Issue

Unit Price Total Price

(Maximum

NTE)

Base Rate Transport

(Using Bing Maps) One-Way

Trip

0001 (A0427) Advanced Life Support Urgent Transport, Level 1 (ALS 1) Advanced Life Support (ALS) ambulances transport patients who need a higher level of care during transport above those services provided by a BLS ambulance. The unit is staffed by at least one paramedic who has more than 1,000 hours of education and training and are qualified to render advanced life support to patients such as advanced airway management, drug administration and cardiac monitoring under the direction of a hospital. (base rate to include first 25 miles) One-way trip is equivalent to one each for the unit of issue

30 Maximum (One-Way Trips)

Per Trip (One-Way)

0002 (A0428) Basic Life Support, Non- Emergency Transport, Basic Life Support (BLS) ambulances provide transport to patients who do not require extra support or cardiac monitoring. A BLS ambulance is staffed by two emergency medical technicians (EMTs) who have training in basic emergency medical care such as basic airway management, use of an automated external defibrillator and basic drug administration. (base rate, to include first 25 miles) One-Way trip is equivalent to one each for the unit of issue

900 Maximum (One-Way Trips)

0003 (A0426) Non-Emergent Advance Life Support Transport, Level 1 (ALS 1) ((base rate to include first 25 miles) One-way trip is equivalent to one each for the unit of issue

30 Maximum

(One-Way Trips)

0004 (A0434) Critical Care Transport (Upper- Level Care) Specialty Care Transport (SCT) – As defined by the Centers for Medicare & Medicaid Services (CMS) — is IFT of a critically injured or ill beneficiary by a ground ambulance vehicle including the provision of medically necessary supplies and services, at a level of service beyond the scope of the EMT-Paramedic SCT is necessary when a beneficiary’s condition requires ongoing care that must be furnished by one or more health

25 Maximum (One-Way Trips) professionals in an appropriate specialty area, for care.

CO’s ADD OTHER NECESSARY LINE

ITEMS, I.E. STRETCHER

TRANSPORTS, ETC. ALL MUST HAVE

BASE RATE. CO’S AND COR’S MUST

ESTABLISH APPROPRIATE BASE RATE

0005 (A0425) Mileage Trip Outside the Base Rate

Price Per Mile

0006 (A0420) Waiting Time (more than 30 minutes shall be paid in 30-minute increments).

$____Each (15-minute Increment)

Base Period (Total Price)