CMS-10785 Air Ambulance Report Template

Air Ambulance Data Report – Providers of Air Ambulance Services
Organization Information
O1

Reporting Period

Submitting Entity Information
O2
Entity Name
O3
FEIN
O4
Point of Contact: Name
O5
Point of Contact: E-mail
Responsible Entity Information
O6
Entity Name
O7
FEIN
O8
Point of Contact: Name
O9
Point of Contact: E-mail
O10
Address: Street
O11
Address: City
O12
Address: State
O13
Address: Zipcode
O14
Organization Type
O15
Parent Company Name
O16
Parent Company FEIN
O17
Number of Bases
O18
NPIs

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

Air Ambulance Data Report – Providers of Air Ambulance Services
Base Information
B1

B2

B3

B4

Base Base Base
LOCID Name City State

B5

Delivery
Model

B6

B7

B8
Air Medical
Subscriptions or
Ambulance/EMS
Number
Names of
of Payor Contracted Membership
Contracts Payors
Programs

B9
NonDirect
Payor
Contracts

B10
Are
Operational
Costs
Shared with
Others

B11
Does the
Base
Operate
Ground
Ambulances

B12
Total
Number
of
Responses

B13
Number
of
NonTransport
Responses

Air Ambulance Data Report – Providers of Air Ambulance Services
Vehicle Information
BV1

BV2

BV3

BV4

Aircraft
Base NAircraft
LOCID Name Number Type

BV5

BV6

Aircraft Flight
Use
Equipment

BV7

BV8

BV9

Number of
Scene
Response
Patient
Transports

Number of
Inter-Facility Number
of Other
Patient
Transports
Transports

BV10

BV11

Average
Number
of Flight
Staff

Average
Number
of
Medical
Staff

Air Ambulance Data Report – Providers of Air Ambulance Services
Labor Costs
Base LOCID
Base Name
Base-Level
Labor Costs
Type
Total Staff
Count
Hours
Salaries and
Wages
Incentive
Compensation
Benefits
Workers
Compensation
Payroll Taxes
Other
Comments

From B1
From B2

Response Staff

Administrative/Facility Staff
Dispatch
Medical
/ Call
Vehicle
Facilities
Regional and
Pilots Physicians Nurses Paramedics Director Administrative Management Center
Maintenance Maintenance Corporate

Air Ambulance Data Report – Providers of Air Ambulance Services
Facility Costs
Base LOCID
Base Name

Base-Level Facility Costs
Annual Lease/Rental Costs, if
not owned
Annual Mortgage, Bond
Interest, Other Ownership
Annual Depreciation
Insurance
Maintenance &
Improvements
Utilities
Taxes
Computers & Software
Other (specify)
Comments

From B1
From B2

Hangars

Landing
Pads

Control
Crew
and Radio
Quarters Towers

Dispatch
Centers Administrative

Other

Regional and
Corporate

Air Ambulance Data Report – Providers of Air Ambulance Services
Vehicle Costs
Base LOCID
Base Name

From B1
From B2

Air Ambulances
Aviation Vendor Fees
Depreciation
Conversion to Air Ambulance
Safety enhancements
Other non-medical equipment (such as
radios/communication systems)
Registration & License
Interest
Tax
Insurance
Maintenance Equipment & Parts
Fuel
Capital Medical Equipment
Other (specify)
Other Vehicles
Vendor Fees
Depreciation
Registration & License
Tax
Insurance
Maintenance Equipment
Fuel
Other (specify)
Comments

Aircraft NAircraft NNumber from BV3 Number from BV3

Aircraft NAircraft NNumber from BV3 Number from BV3

Fire Trucks /
Rescue Vehicles

Other Vehicles

Ground
Ambulances

Regional and
Corporate

Air Ambulance Data Report – Providers of Air Ambulance Services
Equipment and Supply Costs
Cost Type
Capital Non-Medical Equipment
Uniforms
Other Non-Medical
Capital Medical Equipment
Medications
Medical Equipment, Supplies, and Consumables
Other (specify)
Comments

Base LOCID
from B1

Base LOCID Base LOCID
from B1
from B1

Base LOCID Regional and
from B1
Corporate

Air Ambulance Data Report – Providers of Air Ambulance Services
Vendor Costs
Cost Type
Billing Service
Accounting/Finance
Vehicle Maintenance/Repair Service
Dispatch/Call Center
Facilities Maintenance Services
IT Support Service
Response Labor
Medical Direction/Management
Aviation Direction/Management
Other (specify)
Comments

Base LOCID
from B1

Base LOCID Base LOCID
from B1
from B1

Base LOCID Regional and
from B1
Corporate

Air Ambulance Data Report – Providers of Air Ambulance Services
Overhead Costs
Cost Type
Medical or Air Ambulance-Related Expenses
Administrative and General Expenses
Funds paid to other organizations for services
Fees, fines, and taxes
Insurance
Aircraft Liability
Aircraft Hull
Medical Malpractice
General liability
Other
Training
Non-Medical
Medical
Other (specify)
Comments

Base LOCID
from B1

Base LOCID
from B1

Base LOCID
from B1

Base LOCID
from B1

Regional and
Corporate

Air Ambulance Data Report – Providers of Air Ambulance Services
Revenue
Revenue Source (Air Ambulance Transports)
Medicare FFS
Medicare Advantage
Medicaid
Veterans Health Administration (VA)
TRICARE
Indian Health Service (IHS)
Commercial Health Coverage or Insurance
Workers Compensation
Patient Cost Sharing
Patient Self-pay
Non-direct Payer Contracts
Other (specify)

Base LOCID
from B1

Base LOCID
from B1

Base LOCID
from B1

Revenue Source (Other)
Contracts with facilities (hospitals, nursing homes, prisons, businesses)
EMS services other than transports (excluding contracts with facilities reported above)
Sub-contracted ambulance services
Fees for standby events
Air medical subscriptions and ambulance or EMS membership programs
Non-direct contracts (waiver, rental, lease, supplemental arrangements)
Charitable donations and foundation funding
Program-related investments
Local taxes or assessments earmarked for EMS services
Enterprise funds and utility rates
Contract revenue from local governments in return for services
Sales of assets and services
Bond or debt financing
State or local donation of vehicles or durable equipment
Technical assistance (subsidized training)
Funding grants and time-limited funding from government (federal, state, local, other)
Other

Comments

Base LOCID
from B1

Base LOCID
from B1

Regional and
Corporate

Base LOCID Base LOCID Base LOCID Regional and
from B1
from B1
from B1
Corporate

Air Ambulance Data Report – Providers of Air Ambulance Services
Transport Data
T1

T2

Base
LOCID Name

T3

T4

Aircraft
NNumber

Date of
Service

T15

T16

T17

Primary
Payor

NonContracted Direct
Contract
Payor
Name
Type

T5

T6

T7

T8

T9

T10

T11

T12

T13

T14

NPI

NPI
Street
Address

NPI
City

NPI
State

NPI
Zipcode

CPT /
HCPCS
Code

Loaded
Statute
Miles

Pick-up
Location
Zipcode

Drop-off
Location
Zipcode

Duration
of Flight
(HH:MM)

T18

T19

T20

T21

Was
Emergent Transport Claim
Denial
Transport Type
Denied? Reason

T27

T28

T29

T30

T31

Paid
Amount –
Base Rate

Paid
Amount –
Mileage

Paid
Amount
– Other

Paid
Patient Cost
Amount –
Sharing
Other Payors Amount

T22

T23

T24

T25

T26

Was Claim
Denial
Appealed?

Was Claim
Paid after
Appeal?

Submitted
Charge –
Base Rate

Submitted
Charge –
Mileage

Submitted
Charge –
Other

T32

T33

T34

T35

T36

Amount
Billed to
Patient

Was Bill
Referred to
Collections?

Amount
Received
from
Patient

Other
Reimbursement

Type of Other
Reimbursement

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.