- Applies to
- Ambulance services coverage
- Ambulance services authorizations
- Medicare ambulance services billing
- HCPCS procedure codes
- Ambulance services clinical edit
Priority Health Medicare Advantage plans follow Medicare rules, below
"Ambulance" includes a motor vehicle or aircraft that is primarily used or designated as available to provide transportation and basic life support, limited advanced life support, or advanced life support.
Emergent transportation is defined as dispatched by a 911 call, whether or not the patient agrees to be taken to the hospital.
Ambulance stabilization is defined as ambulance response, non-transport. The patient is treated and stabilized but no transport is made.
In a medical emergency, all plans cover EMT and ambulance transport to the nearest medical facility that can provide medical emergency care.
Non-emergent transportation, including medically necessary transfer between facilities, is covered without prior authorization.
Non-transport stabilization services
Covered for commercial, Medicare and Medicaid members.
Medicare covers ambulance services, including fixed wing and rotary wing ambulance services, only if they are furnished to a beneficiary whose medical condition is such that other means of transportation are contraindicated. The beneficiary's condition must require the ambulance transportation itself and the level of service provided in order for the billed service to be considered medically necessary.
Ambulance services are divided into different levels of ground (including water) and air ambulance services based on the medically necessary treatment during transport.
Medicaid plans cover some services that other plans do not, such as EMT/ambulance treatment on scene without transport. Refer to the Medicaid Provider Manual.
Prior authorization is required for:
Fixed-wing transports, emergent and non-emergent
Authorization is not required for:
Emergency ground and helicopter ambulance services
Non-emergent ground ambulance services
Ambulance services provided to Priority Health Medicare Advantage members, as detailed by CMS, must be reported with the appropriate ambulance HCPCS code. Transport services claims must include the correct origin and destination modifiers or the service will be denied. Use the Health Care Procedure Coding System (HCPCS) procedure codes below to describe the type and level of services rendered by the ambulance crew.
For emergent transport, when correctly authorized, if necessary (see above), and when the correct origin and destination modifier combination are submitted next to the procedure code
For ambulance stabilization, non-transport, do NOT include modifier
When fixed-wing and non-emergency ambulance services are not authorized in advance
When codes/modifiers are missing
When any submitted diagnosis code on the claim has a description that includes the word "unspecified"
Taken from the WPS website Ambulance Procedure Codes page:
A0425: Ground mileage, per statute mile
A0426: Ambulance service, advanced life support, non-emergency transport, level 1 (ALS1)
A0427: Ambulance service, advanced life support, emergency transport, level 1 (ALS1- Emergency)
A0428: Ambulance service, basic life support, non-emergency transport (BLS)
A0429: Ambulance service, basic life support, emergency transport (BLS-Emergency)
A0430: Ambulance service, conventional air services, transport, one way (fixed wing) (FW)
A0431: Ambulance service, conventional air services, transport, one way (rotary wing) (RW)
A0433: Advanced life support, level 2 (ALS2)
A0434: Specialty care transport (SCT)
A0435: Fixed wing air mileage, per statute mile
A0436: Rotary wing air mileage, per statute mile
A0888: Non-covered ambulance mileage, per mile (e.g., for miles traveled beyond closest appropriate facility)
A0998: Ambulance response and treatment, no transport (covered by Priority Health Medicare, not by Original Medicare); do NOT include modifier
Report origin and destination modifiers with transport claims
For ambulance transport service claims, institutional-based providers and suppliers must report an origin and destination modifier for each ambulance trip provided in HCPCS/Rates.
Origin and destination modifiers used for ambulance services are created by combining two alpha characters. Each alpha character, with the exception of "X", represents an origin code or a destination code. The pair of alpha codes creates one modifier. The first position alpha code equals origin; the second position alpha code equals destination. Origin and destination codes and their descriptions are listed below, and on the WPS website (Note: Do NOT include a modifier with A0998):
D = Diagnostic or therapeutic site other than P or H when these are used as origin codes
E = Residential, domiciliary, custodial facility (other than 1819 facility)
G = Hospital-based ESRD facility
H = Hospital
I = Site of transfer (e.g. airport or helicopter pad) between modes of ambulance transport
J = Freestanding ESRD facility
N = Skilled nursing facility
P = Physician office
R = Residence
S = Scene of accident or acute event
TN = Rural/outside provider's customary service area
X = Intermediate stop at physician office on way to hospital (destination code only)
Ambulance Required Modifiers for Ambulance Service HCPCS Code Rule
Professional claims, all products: Ambulance origin and destination modifiers should be appended to ambulance services. Ambulance codes that are missing origin and destination modifiers will be denied. Exception – an ambulance service will not be denied for missing origin and destination modifiers if modifier QL is appended to indicate the patient was pronounced dead after the ambulance was called.
Facility claims, all products: Ambulance origin and destination modifiers should be appended to ambulance services. A modifier indicating whether the service was provided under arrangement or directly should also be appended. Ambulance codes that are missing origin and destination modifiers and/or a modifier to indicate whether the service was provided under arrangement or directly will be denied. Please refer to the Ambulance services page in the Provider Manual for exceptions and further information.
Ambulance During Inpatient Stay
Professional claims, all products: Ambulance services are not separately payable when reported with a date of service within an admission and discharge date of an inpatient claim per PH payment policy. The service is considered bundled to the inpatient stay and will be denied. The edit will not apply if the service was provided on the day of admission or day of discharge of the inpatient stay. Ambulance services provided during an inpatient leave of absence (LOA) that have been denied with the edit may be reconsidered via the Reviews & Appeals process.