Reporting Requirements Regarding Air Ambulance Services – Plans, Issuers, and FEHB carriers

OMB Control Number: 0938-XXXX
Expiration Date: xx/xx/xxxx

Air Ambulance Data Report Instructions – Group Health
Plans, Health Insurance Issuers, and FEHB Carriers
Background & Purpose
Section 9823 of the Internal Revenue Code (the Code), section 723 of the Employee Retirement Income Security Act (ERISA), and section 2799A8 of the Public Health Service Act (PHS Act), as added by section 106(b) of the No Surprises Act, require group health plans and health insurance
issuers to submit data on air ambulance services provided to participants, beneficiaries, and enrollees, as applicable, to the Departments of the
Treasury, Labor (DOL), and Health and Human Services (HHS) (collectively, the Departments). The Departments and the Office of Personnel
Management (OPM) proposed implementing regulations at 5 CFR part 890; 26 CFR part 54; 29 CFR part 2590; and 45 CFR part 149. The Centers
for Medicare and Medicaid Services (CMS) is collecting these air ambulance data on behalf of the Departments.
These are the Instructions for the Air Ambulance Data Report (AA Report). The purpose of this document is to provide instructions and
definitions for submission of the required air ambulance data to CMS. The required data elements are described in the proposed 45 CFR
149.230. These Instructions provide information on the organizational responsibility for reporting, the deadlines and reference period for the
data submission, definitions, instructions for the specific data fields, and the submission process.

Applicability of Reporting Requirements
These reporting requirements apply to all group health plans (plans), health insurance issuers offering group or individual health insurance
coverage (issuers), and Federal Employees Health Benefits carriers (FEHB carriers) subject to section 9823 of the Code, section 723 of ERISA, and
section 2799A-8 of the PHS Act as well as the implementing regulations at 5 CFR part 890; 26 CFR part 54; 29 CFR part 2590; and 45 CFR part
149. For self-funded group health plans, the plan sponsor is the responsible entity. The responsible entity may engage a third party (such as a
third-party administrator (TPA)) to submit the air ambulance data on their behalf. We refer to the entity that submits the data to CMS as the
submitting entity.
These reporting requirements apply to grandfathered health plans. These reporting requirements do not apply to excepted benefits, short-term
limited-duration insurance, and health reimbursement arrangements and other account-based group health plans. In addition, plans, issuers,

and FEHB carriers are required to submit AA Reports to CMS only if during the 2022 and/or 2023 calendar years, they receive, incur, or pay for
claims for air ambulance services.

Deadlines and Reference Period for Data Submission
The AA Report reflecting the data for the 2022 calendar year reporting period must be submitted to CMS by March 31, 2023. The AA Report
reflecting the data for the 2023 calendar year reporting period must be submitted to CMS by March 30, 2024. The AA Report must include data
relevant to air ambulance services furnished within the reporting period, as well as data relevant to air ambulance services with payment dates
that fall within the reporting period.

Submission Process
The data collection system for air ambulance data is under development. CMS will update both the information collection section of the
rule and these instructions, as well as provide additional guidance regarding the submission process, once the technical development of
the data collection system has been completed.

Paperwork Reduction Act Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid Office
of Management and Budget (OMB) control number. The valid OMB control number for this information collection is 0938-XXXX. The time required
to complete this information collection is estimated to average 24 hours per response, including the time to review instructions, to make IT changes
to collect, consolidate and report the required information, in the required format, to HHS. If you have comments concerning the accuracy of the
time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail
Stop C4-26-05, Baltimore, Maryland 21244-1850.

Organization Information

This section collects identifying information about your organization.
Item
Number
O1
O2
O3
O4
O5
O6

Data Element

Instructions

Reporting Period
Submitting Entity Name
Submitting Entity FEIN
Submitting Entity Point of Contact: Name
Submitting Entity Point of Contact: E-mail
Responsible Entity Name

O7

Responsible Entity FEIN

Enter 2022 or 2023, as applicable.
Enter the name of the entity submitting the data.
Enter the FEIN of the entity submitting the data.
Enter the name of the point of contact for the entity submitting the data.
Enter the email for the point of contact for the entity submitting the data.
If the AA Report contains data for a single responsible entity, enter the name of the
plan, issuer, or FEHB carrier.
If the AA Report contains data for multiple responsible entities, enter “Multiple.”
If the AA Report contains data for a single responsible entity, enter the FEIN of the
plan, issuer, or FEHB carrier.
If the AA Report contains data for multiple responsible entities, leave blank.

Claims Data

This section collects claims data on air ambulance services provided to participants, beneficiaries, and enrollees, as applicable, of the responsible
entity.
•

For each claim, please provide the line-level detail or header-level detail as required by the data element. For example, there may be
several CPT/HCPCS code(s) and modifier(s) per claim.

Item
Data Element
Number
C1
Plan Name
C2

Issuer or Plan Sponsor Name

C3

Issuer or Plan Sponsor FEIN

C4

Market Type

C5
C6
C7
C8
C9
C10
C11

FEHB Plan Code
Date of Service
NPI
NPI Street Address
NPI City
NPI State
NPI Zipcode

Instructions
Enter the name of the group health plan. If responsible entity is a health insurance issuer and the
plan is fully-insured, leave blank.
For group health plans: enter the name of the plan sponsor. If the responsible entity is a health
insurance issuer and the plan is fully-insured, leave blank.
For health insurance issuers (if issuer is not the submitting entity): enter the name of the issuer.
If already reported in Organization Information section, leave blank.
For group health plans: enter the FEIN for the plan sponsor. If the responsible entity is a health
insurance issuer and the plan is fully-insured, leave blank.
For health insurance issuers (if issuer is not the submitting entity): enter the FEIN of the issuer.
If already reported in Organization Information section, leave blank.
Select the market type for the responsible entity:
• Individual
• Small group
• Large group
• Self-insured Small Group
• Self-insured Large Group
• FEHB
For FEHB claims, enter the plan code for the plan.
Enter the date of the transport.
Enter the National Provider Identifier (NPI) used for billing for this transport.
Enter the street address for the NPI holder used for billing for this transport.
Enter the city for the National Provider Identifier used for billing for this transport.
Enter the state for the National Provider Identifier used for billing for this transport.
Enter the zipcode for the National Provider Identifier used for billing for this transport.

Item
Data Element
Number
C12
CPT/HCPCS Code

Instructions

C13
C14
C15
C16

Loaded Statute Miles
Pick-up Location Zipcode
Drop-off Location Zipcode
Aircraft Type

C17

Contracted Provider

List all CPT/HCPCS codes related to this transport. Include CPT/HCPCS modifiers in parentheses next
to the respective CPT/HCPCS code.
Enter the number of loaded statute miles for this transport.
Enter the pick-up location zipcode for this transport.
Enter the drop-off location zipcode for this transport.
Indicate whether the aircraft is:
• Fixed-wing
• Rotary
Select Y/N to indicate whether the air ambulance services were provided by a contracted provider.

C18

Emergent Transport

Select Y/N to indicate whether the transport was deemed emergent or not.

C19

Inter-Facility Transport

Select Y/N to indicate whether the transport was an inter-facility transport.

C20

Delivery Model

C21

Was Claim Denied?

If known, select the service delivery model of the provider:
• Independent
• Hospital-owned or sponsored
• Hospital-Independent Partnership (hybrid)
• Municipality-sponsored (include public agency programs)
• Tribally-operated Program in Alaska
Select Y/N to indicate whether the claim submitted to the payor was denied.

C22

Denial Reason

Enter the denial reason code.

C23

Was Claim Denial Appealed?

Select Y/N to indicate whether the claim denial was appealed.

C24

Was Claim Paid after Appeal?

Select Y/N to indicate whether the denied claim was paid after appeal.

C25

Submitted Charge – Base
Rate
Submitted Charge – Mileage
Submitted Charge – Other

Enter the amount of the submitted base rate charge for this transport.

C26
C27

Enter the amount of the submitted mileage charge for this transport.
Enter the amount of submitted charges not included in the base rate and mileage charges for this
transport. Other submitted charges include payments for intervention or ancillary services such as

Item
Data Element
Number

Instructions

C28

Paid Amount – Base Rate

oxygen administration, blood administration, ultrasound, etc. These services would have unique
CPT/HCPCS codes (such as A0422 for oxygen administration or 86900 for blood administration).
Enter the amount paid by the primary payor for the base rate for this transport.

C29
C30

Paid Amount – Mileage
Paid Amount – Other

Enter the amount paid by the primary payor for the mileage for this transport.
Enter the amount paid by the primary payor for other charges.

C31

Cost Sharing Amount

Enter the cost sharing amount that is the responsibility of the patient for this transport.