Utilization Management Policy for Emergent and Non‑Emergent Ambulance Services
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Policy governing coverage and utilization management for emergent and non-emergent ambulance transports (ground and air, including gurney/bed-confined transport) for Astiva Health beneficiaries; affects providers requesting or furnishing ambulance services to members.
No material clinical or coverage changes in this revision.
Coverage criteria for ambulance transports
Covered and conditional ambulance transports
Covered when ALL of the following apply according to transport type
General emergent coverage
- Emergent no prior auth: Use of ambulance is covered without prior authorization when the member reasonably believes there is an emergency medical or psychiatric condition that requires ambulance transport to access emergency health care services.
Ambulance services that do not meet the stated coverage criteria are not covered. This includes cases where required documentation of medical necessity is missing or incomplete, and where prior authorization was required but not obtained for non-emergent gurney/bed‑confined transports. Providers should submit the member's mobility status and the transportation purpose when requesting approval for non‑emergent gurney transport; requests lacking this information may be denied as not covered.
When none of the Appendix A conditions are present, additional documentation must be obtained because the following situations frequently do not meet medical necessity: the patient's condition would not ordinarily require stretcher movement; the individual was not admitted as a hospital inpatient (except accident cases); the ambulance was used solely because other transportation was unavailable; or the individual merely needed assistance getting to a vehicle. In these circumstances, the submission must clearly demonstrate why ambulance transport was medically necessary based on the clinical elements in Appendix A.
Coding and billable codes
| No codes listed |
Provider actions, prior authorization, and documentation requirements
Prior authorization required for non-emergent gurney transport
Prior authorization is required for all non-emergent gurney transportation of bedbound/bed-confined patients; all non-emergent requests submitted by a provider will be reviewed for medical necessity. The patient's mobility status and transportation purpose must be provided when submitting the request for approval.
- Submit patient's mobility status
- Include transportation purpose
Provider must document medical necessity and required details for non‑emergent requests
Providers must include clinical justification showing the member’s condition contraindicates other transport methods and must submit required mobility and purpose details for non-emergent gurney/bed-confined requests; failure to provide these elements may result in denial.
- Document that other means of transportation could endanger the member’s health
- For gurney/bed-confined requests, supply mobility status and transportation purpose
- If Appendix A conditions are not present, provide additional documentation to establish medical need
Documentation requirements for non-emergent ambulance requests
For non-emergent ambulance requests, documentation must demonstrate that the member's condition is such that other means of transportation could endanger the person's health; for non-emergent gurney/bed‑confined transports, include the patient's mobility status and transportation purpose. If none of the Appendix A conditions apply, obtain additional documentation to establish medical need.
- Show how other transport could endanger health (medical necessity)
- Include mobility status and transportation purpose for gurney/bed‑confined patients
- If Appendix A conditions absent, provide further supporting documentation
Denial risk for services not meeting coverage criteria
Ambulance services that do not meet the stated coverage criteria — including failure to obtain required prior authorization for non‑emergent gurney/bed‑confined transports or lack of medical necessity documentation — are not covered and may be denied.
- Missing prior authorization for non‑emergent gurney transports risks denial
- Insufficient documentation that other transport would endanger health risks denial
Background
Ambulance transport is intended for patients whose medical condition contraindicates transport by other means because such transport could endanger the member’s health. Covered emergency ambulance use does not require prior authorization when the member reasonably believes an emergency exists. For non‑emergent gurney or bed‑confined transports, prior authorization is required and will be reviewed for medical necessity using the Appendix A clinical elements (e.g., need for stretcher, unconsciousness, required oxygen/treatment, bed‑confined status). Air ambulance is reserved for situations where ground transport would endanger life or is inaccessible or too slow.
Definitions
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