CurrentAnthemPolicy G-07036

Transportation Services: Ambulance and Non-Emergent Transport

Defines Anthem Blue Cross and Blue Shield Medicaid reimbursement rules for ambulance and non-emergency medical transport (NEMT) for Ohio Medicaid Managed Care members, including what is reimbursable and nonreimbursable and coding/billing expectations.

Policy Summary

PayerAnthem

PolicyTransportation Services: Ambulance and Non-Emergent Transport

Policy CodePolicy G-07036

Change TypeRemoval of ambulance base rate when no transport provided

Effective DateMay 22, 2024

Next Review DateN/A

Key ActionFollow authorization and medical necessity guidelines and bill claims with origin and destination modifiers to avoid denial.

SourceLink

POLICY UPDATE CHANGES

Removed 'Ambulance Base Rate when no transportation is provided (treatment without transport)' from nonreimbursable services for ambulance-only section.

base ratePrimary reimbursement basis for ambulance per trip

mileageMileage reimbursed in addition to base

modifiers requiredOrigin/destination modifiers

multiple itemsSpecific exclusions listed

Coverage and Reimbursement Criteria

Policy Summary

PayerAnthem

PolicyTransportation Services: Ambulance and Non-Emergent Transport

Policy CodePolicy G-07036

Change TypeRemoval of ambulance base rate when no transport provided

Effective DateMay 22, 2024

Next Review DateN/A

Key ActionFollow authorization and medical necessity guidelines and bill claims with origin and destination modifiers to avoid denial.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage criteria

Anthem allows reimbursement for ambulance and non-emergency medical transport when transports are to covered services or contract-mandated services and are to the nearest appropriate facility; claims must meet billing requirements described below.

Transport is to a covered service or to another service mandated by contract, unless otherwise indicated by provider, state, federal, or CMS requirements.

Transport is to the nearest facility equipped to treat the member.

Claims for transportation services must be billed with origin and destination modifiers; claims may be denied if modifiers are not included.

Ambulance reimbursement

Ambulance reimbursement is based on the ambulance base rate per trip in accordance with the appropriate level of care provided to the member.
Services included in the ambulance base rate: disposable/first aid supplies; reusable devices/equipment; oxygen; intravenous (IV) drugs; and ambulance personnel services.
Services reimbursed separately from the ambulance base rate: mileage and an extra ambulance attendant.

Non-emergency medical transport (NEMT) reimbursement

NEMT reimbursement is based on the appropriate mode of transportation for the member's needs.
Services reimbursed for NEMT include: medical transport base rate; additional appropriately licensed medical personnel as needed for the member's health status; mileage; unusual waiting time; and parking and/or toll fees.

Coding, Modifiers, and Reimbursement Components

Modifiers requiredmixedCovered

D	Diagnostic or therapeutic site/free-standing facility other than P or H
E	Residential, domiciliary, custodial facility
G	Hospital-based dialysis facility (hospital or hospital-associated)
H	Hospital (inpatient or outpatient)
I	Site of transfer between two types of ambulance
J	Nonhospital based dialysis
N	Skilled Nursing Facility (SNF), including swing bed
P	Physician's office, including HMO nonhospital facility or clinic
R	Private residence
S	Scene of accident or acute event

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Modifiers usage notemixed

origin/destination modifiers (D, E, G, H, I, J, N, P, R, S, X)

Use origin and destination modifiers as indicated for sites; claims must be billed with origin and destination modifiers or may be denied

Reimbursement components

Primary reimbursement basisAmbulance base rate per trip paid according to the appropriate level of care

MileageReimbursed separately from the ambulance base rate

Extra ambulance attendantSeparately reimbursed when required

NEMT reimbursed componentsMedical transport base rate plus mileage, additional licensed personnel as needed, unusual waiting time, parking/tolls

Authorization, Claim Submission, and Provider Requirements

Prior Authorization

Prior authorization, medical necessity, and claim submission requirements

Services must meet authorization and medical necessity guidelines and be billed following provider manual and state/federal requirements; failure to follow billing/submission guidelines may result in claim rejection, denial, or recovery. Claims for ambulance and NEMT services must be billed with origin and destination modifiers or the claim may be denied.

Follow provider manual and state/federal guidelines for transportation submission requirements.
Use industry-standard CPT/HCPCS/revenue codes supported by the medical record; improper coding/billing can lead to rejection, denial, or recoupment.
Include origin and destination modifiers on all ambulance and NEMT claims to avoid denial.

Definitions

ALS / BLS definitions

Advanced Life Support (ALS)Invasive services provided by personnel trained as EMTs (intermediate or paramedic) in conjunction with applicable state laws

Basic Life Support (BLS)Noninvasive services provided by personnel trained as emergency medical technicians (EMTs) (basic) in conjunction with applicable state laws

Service delineationAmbulance services are delineated as BLS or ALS and further as emergency or non-emergency

Air ambulance definition

Air ambulance definitionAn equipped and staffed aircraft necessary to rapidly transport a member to the nearest appropriate facility when ground transport would endanger the member's health

Aircraft typesAir ambulances may be rotary-wing (helicopter) or fixed-wing (commercial or private aircraft)

Appropriate useUsed when the nearest appropriate facility could not otherwise be reached by ground ambulance without endangering the member

NEMT definition and scope

NEMT definitionTransport of a member by non-medically skilled personnel (e.g., laypersons) to receive covered services

Modes of transportAmbulette/medi-van, wheelchair van, invalid coach, taxicab, mini-bus, public transportation (bus/subway)

Reimbursed NEMT itemsMedical transport base rate, additional licensed personnel as needed, mileage, unusual waiting time, parking/tolls