Ground ambulance and medical transport services — coverage criteria and billing rules
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Defines coverage, medical necessity, and billing rules for ground emergency and non-emergency ambulance transport for Blue Cross Blue Shield - Rhode Island members; applies to providers submitting claims for ground ambulance services.
No material clinical or coverage changes in this revision.
Coverage and Medical Necessity Criteria
Emergency Transports
Emergency ground ambulance services are considered medically necessary when:
If the patient is pronounced dead after the ambulance is called, reimbursement will be made (see QL modifier).
Non-Emergency Transports
Non-emergency ground ambulance transport is medically necessary when ALL of the following are met:
Members residing in a skilled nursing facility (SNF) may be covered for transport to diagnostic or therapeutic sites if bed confined.
Examples of contraindicated conditions include medically unstable, comatose, requires airway or cardiac monitoring, or dependent on a ventilator.
Covered ambulances and related services
Covered when ALL of the following are met:
BCBSRI requires these modifiers; absence of the two-digit origin/destination HCPCS modifier may cause the claim to be denied.
These HCPCS are covered/when medically necessary only when filed with a covered destination modifier combination.
Wheelchair-assisted ground ambulance services are explicitly not covered by this policy. In addition, the following non-emergency HCPCS are listed as non-covered for BlueCHiP for Medicare and Commercial products: A0021, A0080, A0090, A0100, A0110, A0120, A0130. Providers should not bill these HCPCS as covered ambulance services.
No payment will be made for transportation from an acute inpatient facility (hospital, rehabilitation facility, or long-term acute care facility) to another facility for a specialized service when it is expected the member will return to the original facility. Responsibility for providing such transportation lies with the originating facility; claims for ambulance transport in this situation are not payable.
Certain origin/destination modifier combinations are disallowed and will not be covered. For BlueCHiP for Medicare the non-covered destination modifier combinations are EP/PE, RP/PR, NP/PN. For Commercial products the non-covered destination modifier combinations are EP/PE, RP/PR, NP/PN, RG/GR, RJ/JR. Claims using these destination modifier pairs should be avoided as they are excluded by product.
Ambulance transport is considered not medically necessary when other means of transportation could be used without endangering the individual's health. Even if alternative transport is not actually available, if it would not place the patients health at risk, payment for ambulance services may be denied. Appropriate documentation demonstrating that other transportation was contraindicated must be maintained and produced on request; a physician order alone does not automatically establish medical necessity.
HCPCS/CPT Codes, Modifiers, and Mileage Rules
| A0225 | Ambulance service; Neonatal transport, base rate, emergency transport, one way |
| A0425 | Ground mileage, per statute mile |
| A0426 | Ambulance service, advanced life support, non-emergency transport, Level 1 (ALS1) |
| A0427 | Ambulance service, advanced life support, emergency transport, Level 1 (ALS1- emergency) |
| A0428 | Ambulance service, basic life support, non-emergency transport (BLS) |
| A0429 | Ambulance service, basic life support, emergency transport (BLS-emergency) |
| A0433 | Advanced life support, Level 2 (ALS2) |
| A0434 | Specialty care transport (SCT) |
| A0021 | Ambulance service; outside state per mile, transport |
| A0080 | Non-emergency transportation, per mile - vehicle provided by volunteer (individual or organization), with no vested interest |
| A0090 | Non-emergency transportation, per mile - vehicle provided by individual (family member, self, neighbor) with vested interest |
| A0100 | Non-emergency transportation; taxi |
| A0110 | Non-emergency transportation and bus, intrastate or interstate carrier |
| A0120 | Non-emergency transportation: mini-bus, mountain area transports, or other transportation systems |
| A0130 | Non-emergency transportation: wheelchair van |
| A0140 | Non-emergency transportation and air travel (private or commercial) intrastate or interstate |
| A0160 | Non-emergency transportation: per mile case worker or social worker |
| A0180 | Non-emergency transportation; ancillary: lodging-recipient |
| A0190 | Non-emergency transportation; ancillary: meals recipient |
| A0200 | Non-emergency transportation; ancillary: lodging escort |
| A0210 | Non-emergency transportation; ancillary |
| A0432 | Paramedic intercept (PI), rural area transport furnished by a volunteer ambulance company |
| A0888 | Non-covered ambulance mileage |
| A0998 | Ambulance response and treatment, no transport |
| S0209 | Wheelchair van, mileage, per mile |
| A0390 | ALS mileage (per mile) |
| A0392 | ALS specialized service disposable supplies; defibrillation |
| A0394 | ALS specialized service disposable supplies; IV drug therapy |
| A0396 | ALS specialized service disposable supplies; esophageal intubation |
| A0398 | ALS routine disposable supplies |
| A0420 | Ambulance waiting time (ALS or BLS), one-half (1/2) hour increments |
| A0422 | Ambulance (ALS or BLS) oxygen and oxygen supplies, life sustaining situation |
| S0207 | Paramedic intercept, non-hospital-based ALS service (non-voluntary), non-transport |
| S0208 | Paramedic intercept, hospital based ALS service (non-voluntary), non-transport |
| S0215 | Non-emergency transportation, per mile |
| D | Diagnostic or therapeutic site other than -P or -H when these are used as origin codes |
| G | Hospital-based dialysis facility (hospital or hospital related) |
| H | Hospital |
| I | Site of transfer (e.g., airport or helicopter pad) between modes of ambulance transport |
| J | Non-hospital-based dialysis facility |
| N | Skilled nursing facility (SNF) (1819 facility) |
| P | Physician's office |
| R | Residence |
| S | Scene of accident or acute event |
| X | Intermediate stop at physician's office on the way to the hospital (destination only code) |
| EP/PE | Destination modifier combinations not covered |
| RP/PR | Destination modifier combinations not covered |
| NP/PN | Destination modifier combinations not covered |
| RG/GR | Commercial-only non-covered destination modifier combinations |
| RJ/JR | Commercial-only non-covered destination modifier combinations |
Provider Responsibilities, Documentation, and Billing Requirements
Prior Authorization — prior authorization review is not required
Prior authorization review is not required.
Modifier-required covered HCPCS — certain HCPCS covered only when filed with covered destination modifier combination
The following HCPCS are covered when medically necessary only when filed with a covered destination modifier combination. BCBSRI requires origin and destination two-digit modifiers be appended to all ambulance HCPCS codes on claims submissions. Absence of the two-digit origin and/or destination modifier may cause the claim to be denied.
Regulatory and Equipment Requirements — providers must comply with local/state/federal laws and hold proper licenses/equipment
Providers of emergency and non-emergency medical transport services must comply with all local, state, and federal laws, hold all appropriate and valid licenses and permits, and have the necessary patient care equipment and supplies.
Documentation requirement — maintain appropriate documentation of medical necessity; physician order alone insufficient
Maintain appropriate documentation to support medical necessity of ambulance transports. Blue Cross & Blue Shield of Rhode Island follows CMS's definition: ambulance transport is medically necessary when the patient's condition is such that use of any other method of transportation is contraindicated. If some other means of transportation could be used without endangering the individual's health, no payment may be made. A physician's order alone does not by itself establish medical necessity. Documentation must be kept on file and presented upon request.
- The transport must be to obtain a Medicare-covered service or to return from such a service.
- The ambulance service must meet all program coverage criteria for payment to be made.
Missing modifiers may trigger denial — absence of two-digit origin/destination modifiers may cause claim denial
If the origin and/or destination two‑digit HCPCS ambulance modifiers are not present on the claim, BCBSRI may deny the claim. Append the appropriate origin (origin code) and destination (destination code) modifiers to all ambulance HCPCS codes.
- Absence of the two-digit HCPCS ambulance service modifier may cause the claim to be denied.
- Append origin and destination modifiers for all ambulance HCPCS codes on claim submissions.
Provider action — absence of ambulance-necessary condition (other transport adequate) means no payment
If the member's condition does not require ambulance transport (i.e., other transport would not endanger health), do not bill for ambulance — payment will not be made.
Disallowed destination modifier combinations — specific destination modifier combos not covered for BlueCHiP for Medicare and Commercial
BlueCHiP for Medicare: The following destination modifier combinations are not covered: EP, PE, RP, PR, NP, PN.
- Do not bill these combinations for BlueCHiP for Medicare members.
Disallowed destination modifier combinations — specific destination modifier combos not covered for BlueCHiP for Medicare and Commercial
Commercial Products: The following destination modifier combinations are not covered: EP, PE, RP, PR, NP, PN, RG, GR, RJ, JR.
- Do not bill these combinations for Commercial members.
Key Definitions
Background and Scope
Ambulance services are categorized by level of care into Basic Life Support (BLS) and Advanced Life Support (ALS), with specialty care and air/water transport addressed separately. An emergency transport is defined as the sudden onset of acute symptoms where the absence of immediate medical attention could reasonably be expected to place the patients health in serious jeopardy, cause serious impairment to bodily functions, or result in serious dysfunction of any organ or part. This policy follows CMS definitions for medical necessity and applies those definitions when determining coverage for both emergency and non-emergency ground ambulance services.
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