WI EMS Tax Assessment - Provider Data Collection Tool Logo

  • Medicaid Supplemental Payment Program for EMS Providers: Provider Assessment Data Collection Tool

  • Please complete the following form to participate in the Emergency Medical Services Provider Assessment Program authorized under 2021 Wisconsin Act 228. Only one form should be submitted for each eligible ambulance services provider. Questions about the form or the WI Emergency Ambulance Services Provider Assessment program can be directed to WIGEMT@pcgus.com. Data collected will be used solely for the Ambulance Provider Assessment program and will not be published by the Department.

    Please note, all privately owned ambulance service providers operating in the State of Wisconsin are required to complete this form on or before the October 4, 2024 deadline.

    • Contact Details 
    • Provider Details 

    • Your organization's NPI or Medicaid Billing Provider ID can be found on the ForwardHealth portal, under the Demographics section.

      The NPI is a unique 10-digit identification number for covered health care providers to use during administrative and financial transactions.

      The Medicaid Billing Provider ID is a 8 or 9-digit state-assigned unique identifier that is used to identify Medicaid enrolled providers in the State's Medicaid Management Information System (MMIS).

    • Based on your responses, you are not eligible for the Emergency Ambulance Services Provider Assessment program. We will follow up if additional information is needed.

      If you are an emergency ambulance services provider, you may be eligible to participate in the CPE program. Visit the CPE landing page to learn more.

      Please click 'Submit' to submit your responses.

    • Did you provide emergency medical transports under any of the following procedure codes from July 1, 2023-June 30, 2024?

      • A0429 BLS Emergency,
      • A0427 ALS Emergency (Level 1),
      • A0433 ALS Emergency (Level 2),
      • A0434 Specialty Care Transport,
      • A0998 Ambulance response and treatment, no transport, and
      • A0225 Neonatal Emergency Transport

    • Based on your responses, you are not eligible for the Emergency Ambulance Services Provider Assessment program. We will follow up if additional information is needed.

      Please click 'Submit' to submit your responses.

    • Based on your responses, you are eligible for the mandatory Emergency Ambulance Services Provider Assessment program.

      Please click 'Next' and continue to the next page of this form.

  • Service Provision Data

    Please enter the required service provision data as per the definitions provided
    • Definitions 

    • Net Patient Revenue includes all payments received for ambulance services provided in the State of Wisconsin, from all payors, over the twelve-month period of July 1, 2023– June 30, 2024.


      Emergency Ambulance Services includes transport, mileage and medical supplies billed in association with any of the following procedure codes:

      • A0429 BLS Emergency,
      • A0427 ALS Emergency (Level 1),
      • A0433 ALS Emergency (Level 2),
      • A0434 Specialty Care Transport,
      • A0998 Ambulance response and treatment, no transport, and
      • A0225 Neonatal Emergency Transport.

      Emergency Transport Counts include total unique instances of Emergency Ambulance Services, defined above. The transport count should exclude related mileage and supply units. For example, an ALS 1 transport billed under A0427 along with five mileage units should simply be reported as one transport.

      Non-Emergency Ambulance Services includes transport and mileage billed in association with any of the following procedure codes:

      • A0428 BLS Non-mergency,
      • A0426 ALS Non-emergency.

      Non-emergency Transport Counts include total unique instances of Non-emergency Ambulance Services, defined above. The transport count should exclude related mileage and supply units. For example, an BLS non-emergency transport billed under A0428 along with five mileage units should simply be reported as one transport.

      All payors include but are not limited to Medicaid, Medicare, Self-Pay, Commercial payers and Workers' Comp. Revenues not tied to ambulance service billing, such as subsidies and grants, are excluded.

      *All revenues associated with a transport, and the transport count itself, should be included under the category that best matches the primary payor. For example, if the primary payor was Medicare, the revenues and transport count would be included under the “all other payors” category.

      Ambulance services provided in the State of Wisconsin includes all ambulance services with incident/pick-up location in the State of Wisconsin.

    • EMS Service Provision Data 
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    • Estimated results

    • Tax assessments are subject to review and validation. Final assessment bills may deviate from the calculation above. Once finalized, providers will be notified of their tax assessment amount, the calculation basis, the deadline for payments and options for issuing payments.

      *The potential fee is estimated and subject to CMS approval while maintaining compliance with 2021 WI Act 228.

    • Certification 

    • I,*, certify the following:

      1. This submission is true and correct to the best of my knowledge and information;
      2. I attest that {providerFull} will not participate in a mitigation pool or other redistribution arrangement that holds taxpayers of this program harmless for the cost of a tax in violation of federal requirements and under 42 CFR 433.68(f); and
      3. I am the responsible person of {providerFull} and am duly authorized to sign this certification.


      Signed  *  on Pick a Date* .  

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