CurrentBlue Cross Blue Shield - MainePolicy G-07036

Transportation Services: Ambulance and Non-Emergent Transport, Reimbursement Policy

This reimbursement policy governs when AMH Health (Blue Cross Blue Shield - Maine) allows or disallows payment for ambulance and non-emergency medical transport services for covered members, and outlines billing and coding requirements for providers.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyTransportation Services: Ambulance and Non-Emergent Transport, Reimbursement Policy

Policy CodePolicy G-07036

Change TypeMaterial edits to nonreimbursable items

Effective DateMay 22, 2024

Next Review DateN/A

Key ActionBill transport claims with origin and destination modifiers and follow authorization/medical necessity requirements 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.

Added wait time fees and outreach fees to the Nonreimbursable section.

ListedItems bundled into ambulance base rate

SeparateMileage payment policy

RequiredBilling modifier requirement

MultiplePolicy history entries

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.

Reimbursement Criteria and Exclusions

Reimbursement criteria and exclusions

Covered when ALL of the following are met:

AMH Health allows reimbursement for ambulance transport and the services and supplies associated with transportation to the nearest facility equipped to treat the member (nearest appropriate facility rule).

From policy: reimbursement to nearest facility equipped to treat member.

Transport is billed with appropriate origin and destination modifiers; claims may be denied if modifiers are not used.

Origin/destination modifiers required on transport claims.

Reimbursement is based on the ambulance base rate per trip according to the appropriate level of care provided to the member.

Base rate per trip tied to level of care.

Services and supplies listed are included in the ambulance base rate and are not separately reimbursable: reusable devices/equipment, disposable/first aid supplies, oxygen, ambulance personnel services, and intravenous (IV) drugs.

Items bundled into ambulance base rate.

Mileage is reimbursed separately from the ambulance base rate.

Mileage separately reimbursed.

Exclusions — AMH Health does NOT reimburse the following (any):

Non-emergency medical transport (NEMT) is nonreimbursable under this ambulance/medical transport policy.
Mileage when the transport service has been denied or is not covered.
Additional rates for night, weekend, and/or holiday calls.
A member who is not available (no-show).
Unloaded mileage (mileage in transit to pick up or drop off the member).
Mileage for extra attendant or additional passengers.

Billing Modifiers and Facility Rules

Origin/Destination and Related ModifiersModifier

D	Diagnostic or therapeutic site, facility other than P or H (Origin/destination modifier).
E	Residential; domiciliary; custodial facility (Origin/destination modifier).
G	Hospital-based dialysis facility (hospital or hospital-associated) (Origin/destination modifier).
H	Hospital (inpatient or outpatient) (Origin/destination modifier).
P	Physician's office, including HMO non-hospital facility or clinic (Origin/destination modifier).
GM	Multiple members on one trip (used in addition to origin/destination modifiers).
QL	The member died after the ambulance was called (origin/destination modifiers not required with this modifier).
QM	The provider arranged for transportation services (Origin/destination modifier).
QN	Driver certification statement on file (Origin/destination modifier).
TK	Transfer between facilities (site of transfer between two types of ambulance) (Origin/destination modifier).

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Nearest Appropriate Facility Rule

Nearest Appropriate FacilityAmbulance transport should be to the nearest appropriate facility that is equipped to provide the necessary level of care for the member’s condition. If a specialized service is required and the nearest equipped facility is further, documentation must support medical necessity for bypassing a closer facility.

Authorization, Submission and Billing Requirements

Prior Authorization

Authorization, documentation, coding and claim submission requirements

Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis; claims for transportation services must be billed with origin and destination modifiers or the claim may be denied. Providers should refer to the provider manual and applicable state and federal guidelines for submission requirements. Use industry-standard CPT, HCPCS, and revenue codes that are fully supported in the medical record; failure to follow billing/submission guidelines may result in claim rejection or denial, recovery/recoupment of payment, or adjusted reimbursement.

Obtain and document authorization and medical necessity consistent with the procedure and diagnosis.
Bill transport claims with required origin and destination modifiers; omission may lead to denial.
Use industry-standard CPT, HCPCS, and revenue codes and ensure documentation supports billed services.
Follow provider manual and state/federal (including CMS) submission requirements to avoid denials or recoupment.

Key Definitions

ALS — Advanced Life Support

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

Level of careALS is a delineation of ambulance services when higher-level invasive care is required during transport.

Reference sourcesPolicy developed with consideration of CMS, NASEMSO, Optum EncoderPro and state contract.

BLS — Basic Life Support

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

Level of careBLS denotes noninvasive care provided during transport and is distinct from ALS.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyTransportation Services: Ambulance and Non-Emergent Transport, Reimbursement Policy

Policy CodePolicy G-07036

Change TypeMaterial edits to nonreimbursable items

Effective DateMay 22, 2024

Next Review DateN/A

Key ActionBill transport claims with origin and destination modifiers and follow authorization/medical necessity requirements to avoid denial.

SourceLink

On This Page

Transport for a member's or caregiver's convenience.

Transportation vendor/supplier lodging or meals; vehicle maintenance or gas; transport available free of charge.

Ambulance transports other than medical care or where another means of transportation could be used without endangering the member's health.

Separate reimbursement for services/items included in the base ambulance rate.

Reimbursement for a higher level of care when a lower level is more appropriate.

For both basic and advanced life support when ALS services are provided (duplicate ALS/BLS reimbursement).

Services provided on the ambulance by hospital staff (separately billed).

Transport from the member's home to a facility other than a hospital, skilled nursing facility, dialysis facility, or nursing home.

Additional ground and/or air ambulance providers that respond but do not transport the member.

Transport from a facility other than a hospital, skilled nursing facility, dialysis facility, or nursing home to the member's home.

Transport for a member pronounced dead prior to the ambulance being contacted.

Transport of persons other than the member and a medically required attendant who do not require medical attention.

Mileage beyond the nearest appropriate facility (excessive mileage).

Wait time fees and outreach fees.

UsageServices are delineated as BLS or ALS and further as emergency or non-emergency.

NEMT — Non-Emergency Medical Transport

DefinitionNon-Emergency Medical Transport (NEMT): Transport of a member by non-medically skilled personnel (for example, laypersons) to receive covered services.

Vehicle typesIncludes ambulette/medi-van, wheelchair van, invalid coach, taxicab, mini-bus, and public transportation.

Policy stanceNEMT is listed separately and is nonemergency ambulance transportation distinct from emergency ambulance services.

Air ambulance — Air transport

DefinitionAir ambulance: An equipped and staffed aircraft (rotary- or fixed-wing) necessary to rapidly transport a member to the nearest appropriate facility when ground transport would endanger the member's health.

When indicatedUsed when transport to the nearest appropriate facility could not otherwise be accomplished or accessed by ground ambulance without endangering the member's health.

Relation to reimbursementAir ambulances are treated as a mode of ambulance service within the policy's definitions of medically necessary transport to the nearest appropriate facility.