CHAPTER 100: AMBULANCE SERVICE
Section
   100.01   Without charge procedures
   100.02   Billing rates
   100.03   Uncollectible accounts policies and procedures; write-offs
§ 100.01 WITHOUT CHARGE PROCEDURES.
   (A)   Application.
      (1)   An application for without charge service will be taken when a patient requests without charge service only after credit information is taken and it appears that the patient may be eligible for without charge service. Staff may request without charge service for patients whose financial ability to pay is questionable. A signed application must be on file in order for an account to be approved for without charge service.
      (2)   If credit information has not been documented and the application will be based on income, a current credit information sheet shall be completed.
      (3)   Upon receiving the application, the billing service will review the application and make recommendations to the Director according to the eligibility criteria set forth in division (B) below.
   (B)   Eligibility. A patient will be eligible for consideration for without charge services if he or she meets any of the following and has shown proof that he or she has met any recommendations by billing staff.
      (1)   Annual income is below the Federal Poverty Guidelines.
100% of Poverty Level Medicaid Scale
100% of Poverty Level Medicaid Scale
Size of Family
Monthly Income
1
$776
2
1,041
3
1,306
4
1,571
5
1,836
6
2,101
7
2,366
8
2,631
Each additional person
265
      (2)   Eligible for Kentucky Medicaid and has no other identifiable means of making payment for the balance of services not covered by KMAP.
      (3)   Eligible for Kentucky Medicaid must apply.
      (4)   In addition, a patient shall be considered for without charge service is any in- depth financial investigation reveals any of the following:
         (a)   The is no ability to pay or available assets.
         (b)   Patient has expired and has no distributable estate.
         (c)   All available assets are committed to some other essential cause.
   (C)   An award letter will be sent to the requester informing him or her that he or she has been approved, approved conditionally, delayed for further information, or denied. Patients who have had their accounts approved will not be sent a bill. Bills will be continued until such time that the account has received the approval of the Director of the Ambulance Service or his or her designee where applicable as stated in the without charge policy.
   (D)   Exceptions. The Ambulance Service will reserve the right to deny full or partial without charge services to anyone who:
      (1)   Does not qualify under the above guidelines.
      (2)   Does not follow through with any referral made by Ambulance Service billing staff to an outside agency in attempting to obtain payment from a government source such as Medicaid.
      (3)   Abuses/misuses the system.
      (4)   Does not have a medical condition which is determined to be an emergency that requires ambulance transportation.
      (5)   Requests non-emergency transportation but does not have a medical condition that precludes other means of transportation.
(Ord. 0-04-020, passed - -04)
§ 100.02 BILLING RATES.
   The City of Pikeville Ambulance Service billing rates are set as follows:
Item or Application of Device
Price
Item or Application of Device
Price
Mileage
$20.00
Base rate emergency
$2,000.00
Base rate non-emergency
$1,000.00
Base rate return trip after receiving medical treatment when medically necessary
$600.00
Oxygen
$45.00
Waiting time per hour after one hour
$100.00
Extrication equipment for all type and technical rescue (when used)
$600.00
Trauma disposable supplies
$250.00
Basic life support disposable supplies
$150.00
 
The following forms shall be the standard form adopted by the city and shall be used for all ambulance runs.
CITY OF PIKEVILLE AMBULANCE SERVICE   RUN#                                                                    
   SCENE MILEAGE                                            
   DESTINATION MILEAGE                             
(_) Mileage
(_) Base Rate, Emergency
(_) Base Rate Non-Emergency
(_) Oxygen
(_) Waiting time per hour after 1 hour
(_) Extrication equipment of all types and Technical Rescue (when used)
(_) Trauma \ Disposable Supplies
Trauma\Disposable Supply Protocol
   When you have a patient that gets 2 or more of the following items from your unit there will be a "Trauma\disposable charge".
(Please Circle each item used)
Items:
Bag valve mask
Combo pads
Combi-tube
Splinting (all types)
Mast trousers
C-collar
CID
Long Spine Board Kendrick's Extrication Device
Notes
                                                                                                                                                                                                             
                                                                                                                                                                                                             
 
Run#                             
INSURANCE INFORMATION
Responsible Party                                                                                      SS#                            
Medicare                                                           UMWA                                                   
Medicaid                                                            Black Lung                                              
Commercial Carrier (or) Worker's Compensation                                                                           
Address                                                             Policy#                                                     
               Group                                                       
                     
Commercial Carrier (or) Worker's Compensation                                                                            
Address                                                             Policy#                                                     
               Group                                                       
Auto Insurance Carrier                                                                                                                     
Address                                                             Phone#                                                    
               Agent's Name                                          
Insured's Name                                                   Claim #                                                    
Insured's Policy #                                                                                                                              
NON-EMERGENCY TRANSPORT AUTHORIZATION
Medical Transportation services were provided on / / for the patient named below: by The City of Pikeville Fire Department Ambulance Service.
I verify the patient named below was at my office/facility to receive a medical service on / /
                                                                                                             (Medical Provider Signature)
I certify that I have received the above described services by The City of Pikeville Fire Department Ambulance Service.
                                                                                                 (Recipient Signature)
(Ord. 0-04-020, passed - -04; Am. Ord. 2008-008, passed 1-28-08; Am. Ord. 0-2013-007, passed 4-8-13; Am. Ord. 0-2017-27, passed 9-25-17; Am. Ord. O-2024-04, passed 6-10-24)
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