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    v1.0.28
    OpenPayerPolicy UpdatesReimbursement/Payment PolicyAloha Care out‑of‑state air ambulance Prior Auth |…
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    CurrentAloha CarePolicy MP - 31

    Out-of-State Air Ambulance Services

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    Defines clinical and administrative criteria for coverage of fixed-wing air ambulance transport from Hawaii to the continental United States for QUEST Integration (Medicaid) members; applies to inpatient and outpatient settings and affects providers seeking reimbursement for such transports.

    Policy Summary
    PayerAloha Care
    PolicyOut-of-State Air Ambulance Services
    Policy CodePolicy MP - 31
    Change TypeNo material changes
    Effective DateAug 1, 2025
    Next Review DateN/A
    Key ActionObtain prior authorization before scheduling or billing fixed‑wing air ambulance transports.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    6required clinical criteria (A-F) for coverage
    Prior authadministrative requirement
    A0430, A0435applicable HCPCS codes listed
    No foreign transportslimitation

    Coverage Criteria for Out-of-State Fixed-Wing Air Ambulance

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Coverage Criteria for Out-of-State Fixed-Wing Air Ambulance

    Air ambulance services from Hawaii to the continental United States are covered when ALL of the following criteria A–F are met, subject to limitations and administrative guidelines.

    ALL of the following

    • A. The patient has a high risk of imminent death despite optimal treatment available in the state of Hawaii.
    • B. The patient has a diagnosis of a treatable medical or behavioral health condition.
    • C. The out-of-state treatment is medically necessary as defined in chapter 432E of the Hawaii Revised Statues, or for QUEST members under Hawaii Administrative Rules (HAR 1700.1-42).
    • D. The treating physician’s proposed treatment is not available in the state of Hawaii.
    • E. The patient does not have any known contraindications to the out-of-state treatment being sought.
    • F. The patient does not have a short-term expected survival.

    ALL of the following

    • Air ambulance services within and to and from foreign countries are not covered.
    • Air ambulance services are not covered for patients whose condition allows for transport via commercial air transport.
    • Air ambulance services are not covered for patients not meeting all criteria in section III.

    ALL of the following

    • Prior authorization is required.
    • Applicable billing codes: A0430 (Ambulance service, conventional air services, transport, one way - fixed wing) and A0435 (Fixed wing air mileage, per statute mile).

    Applicable Codes

    Applicable HCPCS CodesHCPCS
    A0430Ambulance service, conventional air services, transport, one way (fixed wing)
    A0435Fixed wing air mileage, per statute mile

    Provider Requirements and Authorization

    Prior Authorization

    Prior authorization required for fixed‑wing air ambulance

    Prior authorization must be obtained before providing fixed‑wing air ambulance transport from Hawaii to the continental United States. Include intent to bill HCPCS codes A0430 (Ambulance service, conventional air services, transport, one way — fixed wing) and A0435 (Fixed wing air mileage, per statute mile) when requesting authorization.

    • Request prior authorization in advance of transport.
    • Specify anticipated codes: A0430 and A0435 on the authorization request.

    Definitions

    Air ambulance (fixed wing) — definition (inv-04)
    Service typeFixed (plane) wing air ambulance transport from Hawaii to the continental United States
    Scope of careAssessment and administration of care by specially trained personnel in a specially designed and equipped aircraft within an appropriate, safe, and monitored environment
    Intended patientsCritically ill or injured patients who cannot use commercial flights due to need for life‑supporting equipment or a medical support team
    Transport settingInterstate transfers from Hawaii to the continental U.S.; provided by fixed‑wing aircraft
    Equipment & staffingLife‑supporting equipment and a medical support team available on board as required for the patient’s condition
    Medically necessary — definition (inv-05)
    DefinitionTreatment required because specialized care is not available locally and meets Hawaii statutes or HAR 1700.1-42 for QUEST members
    Legal basisMedical necessity criteria developed with consideration of Hawaii Revised Statutes §432E-1.4 and HAR 1700.1-42
    Application to transportsOut‑of‑state air ambulance covered when proposed out‑of‑state treatment is not available in Hawaii and medical necessity criteria are met
    Decision authorityBenefit determinations subject to member contract language; treating physician may request reconsideration with supporting documentation if they disagree
    Policy Summary
    PayerAloha Care
    PolicyOut-of-State Air Ambulance Services
    Policy CodePolicy MP - 31
    Change TypeNo material changes
    Effective DateAug 1, 2025
    Next Review DateN/A
    Key ActionObtain prior authorization before scheduling or billing fixed‑wing air ambulance transports.
    SourceLink
    On This Page
    Coverage Criteria for Out-of-State Fixed-Wing Air AmbulanceApplicable CodesProvider Requirements and AuthorizationDefinitions