CurrentAlliance HealthPolicy Clinical Coverage Policy No: 15

Ambulance Services

Defines coverage, clinical criteria, exclusions, prior approval and billing-related rules for ambulance services (ground and air) for North Carolina Medicaid beneficiaries. Covers emergency and non-emergency medically necessary transports, service definitions, destinations, and limitations.

Policy Summary

PayerAlliance Health

PolicyAmbulance Services

Policy CodePolicy Clinical Coverage Policy No: 15

Change TypeNo material change

Effective DateApr 1, 2023

Next Review DateN/A

Key ActionObtain prior approval before rendering non-emergency ambulance services across state lines; each trip requires a separate PA and PA number, active for 30 calendar days.

POLICY UPDATE CHANGES

No material clinical or coverage changes — has_material_change=false and no changes provided.

2Transport types covered (ground, air)

30 daysPrior approval validity

40 milesOut-of-state contiguous rule (miles)

Coverage Summary

Defines coverage, clinical criteria, exclusions, prior approval and billing-related rules for ambulance services (ground and air) for North Carolina Medicaid beneficiaries, including emergency and non-emergency medically necessary transports, provider qualifications, mileage definitions, allowable destinations, and limitations. Coverage stance: mixed.

Medical-Necessity Criteria — General

General Coverage Criteria

Medicaid shall cover procedures, products, and services related to this policy when they are medically necessary, and:

ALL of the following

The procedure, product, or service is individualized, specific, and consistent with symptoms or confirmed diagnosis of the illness or injury under treatment, and not in excess of the beneficiary's needs
The procedure, product, or service can be safely furnished, and no equally effective and more conservative or less costly treatment is available statewide
The procedure, product, or service is furnished in a manner not primarily intended for the convenience of the beneficiary, the beneficiary's caretaker, or the provider

Medical-Necessity Criteria — Emergency & Ambulance Services

Specific Criteria Covered (Emergency and Ambulance Services)

Medicaid shall cover emergency and ambulance services when the beneficiary meets the following specific criteria:

ALL of the following

Coverage for emergency services shall be provided to the extent necessary to screen and to stabilize the beneficiary
Emergency services shall not require prior authorization if a prudent layperson acting reasonably would have believed that an emergency medical condition existed
Payment of claims for emergency services shall be based on retrospective review of the presenting history and symptoms of the beneficiary

Medical-Necessity Criteria — Air Medical Ambulance

Air Medical Ambulance Coverage

Air medical ambulance is covered in any one of the following situations:

ONE of

The beneficiary's medical condition requires immediate and rapid ambulance transport that cannot be provided by ground ambulance
The point of pickup is inaccessible by ground vehicle
The beneficiary's condition is such that the time needed to transport by land, or instability of transport by land, to the nearest appropriate facility poses a threat to the beneficiary's survival or endangers the beneficiary's health

Examples of conditions that may require air medical ambulance

Intracranial bleeding requiring neurosurgical intervention
Shock
Major burns requiring treatment in a burn center
Conditions requiring immediate treatment in a hyperbaric oxygen unit
Multiple severe injuries
Life-threatening trauma
ST Segment Elevation Myocardial Infarction (STEMI)
Cerebrovascular accident (CVA)

Ambulance Transport of Deceased Beneficiaries (Covered)

Ambulance transport of a deceased beneficiary is covered in either one of the following situations:

ANY of the following

Beneficiary pronounced dead after dispatch but before loading; provider reimbursed for BLS base rate; no mileage reimbursed; date of service is dispatch date; use QL modifier 'Patient pronounced dead after ambulance called' on the claim
Beneficiary pronounced dead after pick-up but prior to arrival; same reimbursement rules apply as if beneficiary were alive

Billing Rule

Use QL modifier for deceased-after-dispatch cases

When a beneficiary is pronounced dead after ambulance dispatch but before loading, report the QL modifier on the claim. Provider reimbursed at the BLS base rate and no mileage is reimbursable. Date of service is the dispatch date.

Codes: QL

Out-of-State Transport Coverage

Out-of-State (Non-Contiguous) Transport Coverage

Out-of-state services defined and coverage conditions:

ANY of the following

Hospitals/acute medical care/ambulance services more than 40 miles outside NC border are out-of-state services
Services within 40 miles of NC border in contiguous GA, SC, TN, VA are covered to same extent as NC services; providers must obtain Medicaid provider numbers

Prior Authorization

Obtain prior approval for out-of-state non-emergency ambulance transport

Prior approval (PA) is required and must be obtained before rendering out-of-state non-emergency ambulance services. Each trip requires a separate PA process and separate PA number. A granted PA is active for 30 calendar days but does not guarantee payment or beneficiary eligibility.

Mileage and Loaded Miles

Out-of-County and Loaded Mileage

Mileage coverage rules:

ALL of the following

Air medical ambulance air mileage reimbursable based on loaded miles flown (statute miles) including runway taxiing until offload
Ground ambulance loaded mileage reimbursable only for out-of-county transport; in-county loaded ground mileage is not reimbursable

Billing Rule

Mileage billing limitation

Ground loaded mileage is reimbursable only for out-of-county transport; in-county ground loaded mileage is not reimbursable. Air medical ambulance mileage is reimbursable based on loaded statute miles flown and includes the beneficiary's loading point and runway taxiing until offload.

Transport to Behavioral Health Crisis Centers

Criteria required to cover transport of beneficiaries in behavioral health crisis:

ALL of the following

EMS providers have received appropriate education in caring for beneficiaries in behavioral health crisis
EMS system has at least one partnership with a receiving facility that can provide appropriate care
EMS systems must include in its EMS system plan a report on beneficiary experiences and outcomes per DHHS/DHSR/DHB/OEMS rules

Allowed Destinations (Origin and Destination)

Allowed Destinations

Medicaid covers ambulance transports (that meet other requirements) only to the following destinations:

ANY of the following

Hospital
Critical access hospital
Skilled nursing facility
Adult care home
Intermediate care facility for individuals with intellectual disabilities (ICF-IID)
Beneficiary's primary private residence
Dialysis facility for ESRD if beneficiary's condition requires ambulance services
Transfer site (airport or helipad)
Physician's office (non-emergency requires meeting Subsection 3.2.2.2; emergency only if enroute to hospital, need for stabilization, and ambulance continues to hospital immediately after stabilization)
Emergency hospital-to-hospital transport when transferring facility lacks adequate facilities; coverage only to nearest appropriate facility (e.g., between burn centers, neonatal centers, trauma units, PCI centers, stroke centers)
Emergency transport of nursing home resident must meet medical necessity criteria when needed services are unavailable at facility

Non-Emergency Medically Necessary Ambulance Transport

Non-Emergency Medically Necessary Ambulance Transport - Covered Situations

Non-emergency medically necessary ambulance transport is covered for Medicaid beneficiaries only in the following situations:

ALL of the following

Medical necessity indicated when other means of transportation are medically contraindicated (e.g., beneficiary requires stretcher)
Beneficiary needs medical services that cannot be provided in place of residence
Return transportation from a facility that can provide total care to a facility with fewer resources

Appropriate when either

Beneficiary is bed confined and documentation shows stretcher is only safe mode of transportation
Beneficiary's condition, regardless of bed confinement, is such that ambulance transport is medically required

Bed confined definition (ALL must be met)

Unable to get up from bed without assistance
Unable to ambulate
Unable to sit in a chair or wheelchair

Examples when stretcher needed

Contractures creating non-ambulatory status and beneficiary cannot sit
Immobility of lower extremities (spica cast, fixed hip joints) and unable to be moved by wheelchair
Return (back) transport such as stabilized newborn moved back to referring hospital

Ambulance Services during Pregnancy

Ambulance Services during Pregnancy (Covered when complications)

Ambulance services for pregnant beneficiaries must be medically necessary; medical necessity present if any condition below occurs:

ANY of the following

Crowning
Hemorrhage
Preterm labor (prior to 37 weeks)
Premature rupture of membranes
Abruptio placenta
Placenta previa
Pre-eclampsia or eclampsia
Transport from a small hospital to tertiary hospital when beneficiary is in preterm labor

Prior Approval Requirements

Prior approval (PA) requirements for non-emergency and out-of-state transports:

ALL of the following

PA is required for non-emergency ambulance services by ground or air from North Carolina to another state, from one state to another, or from another state back to North Carolina
PA must be obtained before rendering out-of-state non-emergency ambulance services
PA is not required for in-state emergency ambulance services (ground or air)
PA for ambulance service is separate from PA for a medical procedure or treatment provided out of state
PA does not guarantee payment, beneficiary eligibility on date of service, or preclude post-payment review
Requestor must submit beneficiary face sheet and other relevant information demonstrating emergency medical condition as defined in 42 C.F.R. 489.24(c)(3)

Prior approval submission and duration

Each trip requires a separate PA process and PA number
For non-emergency medically necessary ambulance transport, PA shall be obtained before service is rendered
The PA is active for 30 calendar days

Documentation Required

Submit supporting records for PA and retrospective review

For PA requests and retrospective review, submit the beneficiary face sheet and all supporting health records. Records must demonstrate that the beneficiary met the applicable coverage criteria, including documentation demonstrating an emergency medical condition per 42 C.F.R. 489.24(c)(3).

Documentation Required

Verify Medicaid eligibility at time of service

Providers must verify each Medicaid beneficiary's eligibility at the time the service is rendered. The beneficiary must be eligible on the date of service for payment to be made.

Provider Actions & Billing Rules

Prior Authorization

Obtain prior approval for out-of-state non-emergency ambulance transport

Prior approval is required before providing out-of-state non-emergency ambulance transport. Each trip requires a separate PA and PA number; the PA is active for 30 calendar days. Obtain PA from the fiscal agent prior to service.

Documentation Required

Submit supporting records for PA and retrospective review

Submit the beneficiary face sheet and all relevant health records and documentation that support that the beneficiary met specific coverage criteria when requesting PA or during retrospective review.

Billing Rule

Use QL modifier for deceased-after-dispatch cases

Use the QL modifier when the beneficiary is pronounced dead after dispatch but before loading. Reimbursement is limited to the BLS base rate and no mileage is reimbursed.

Documentation Required

Verify Medicaid eligibility at time of service

Verify each Medicaid beneficiary's eligibility on the date of service; eligibility on the service date is required for payment.

Billing Rule

Mileage billing limitation

Ground loaded mileage is reimbursable only for out-of-county transports; in-county ground loaded mileage is not reimbursable. Air mileage is reimbursable based on loaded statute miles flown and includes the loading point and runway taxiing until the beneficiary is offloaded.

Background & Definitions

Policy defines ambulance services for NC Medicaid beneficiaries including emergency and non-emergency transports by ground and air, provider qualifications, mileage definitions, and allowable destinations. Ground and air ambulance definitions and vehicle/equipment requirements reference State OEMS rules (10A NCAC 13P sections) and OEMS permit/inspection requirements.

The policy references federal definitions for emergency medical condition, specifically 42 C.F.R. 489.24(b), and describes emergency response and immediate response standards tied to BLS and ALS1 levels of care.

Operational context: providers and vehicles must comply with State OEMS licensure, permit, staffing, and equipment rules; out-of-state contiguous coverage requires providers to obtain an N.C. Medicaid provider number; and prior approval procedures for out-of-state non-emergency transport require submission of documentation demonstrating an emergency medical condition per 42 C.F.R. 489.24(c)(3).

Definitions

Policy details

OpenPayer

Ambulance Services

Coverage Summary

Medical-Necessity Criteria — General

Medical-Necessity Criteria — Emergency & Ambulance Services

Medical-Necessity Criteria — Air Medical Ambulance

Ambulance Transport of Deceased Beneficiaries (Covered)

Out-of-State Transport Coverage

Mileage and Loaded Miles

Transport to Behavioral Health Crisis Centers

Allowed Destinations (Origin and Destination)

Non-Emergency Medically Necessary Ambulance Transport

Ambulance Services during Pregnancy

Prior Approval Requirements

Coding

Provider Actions & Billing Rules

Background & Definitions

Revision History