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    v1.0.28
    OpenPayerPolicy UpdatesClinical/Medical PolicyConnectiCare Ambulance Prior Auth | OpenPayer
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    CurrentConnectiCarePolicy M20200049

    Non-Emergent Ambulance Services

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    This policy governs medical necessity criteria for non-emergency ambulance transportation for ConnectiCare Medicare and commercial members in Connecticut.

    Policy Summary
    PayerConnectiCare
    PolicyNon-Emergent Ambulance Services
    Policy CodePolicy M20200049
    Change TypeNo material change
    Effective DateSeptember 11, 2026
    Next Review DateN/A
    Key ActionSubmit clinical evidence and supporting information demonstrating that the member meets the applicable non-emergent ambulance medical necessity criteria for prior authorization.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    2Coverage pathways
    3Procedure codes
    3Bed-confined conditions
    1+Qualifying condition threshold

    Medical Necessity Criteria

    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.

    Procedure Codes

    Procedure CodesHCPCS
    A0425Ground mileage, per statute mile
    A0426Ambulance service, advanced life support, nonemergency transport, level 1 (ALS 1)
    A0428Ambulance service, basic life support, nonemergency transport, (BLS)

    Authorization and Documentation Requirements

    Prior Authorization

    Submit prior authorization with clinical evidence

    The treating physician or primary care provider must submit clinical evidence and supporting information to ConnectiCare for prior authorization, demonstrating that the member meets the applicable non-emergent ambulance medical necessity criteria.

    Documentation Required

    Submit evidence supporting medical necessity

    The treating physician or primary care provider must submit clinical evidence that the patient meets the criteria for the requested service. Without this documentation and information, ConnectiCare will not be able to properly review the request for prior authorization.

    Documentation Required

    Document oncology-related medical necessity

    When chemotherapy or radiation therapy is cited as the reason for ambulance transportation, document medical necessity in the medical record, such as extreme weakness or debility.

    Denial Risk

    Confirm ambulance transportation and destination eligibility

    Transportation may not meet medical necessity when the member can safely use another means of transportation or when the destination is not appropriate under the applicable Medicare or commercial criteria.

    • Other transportation may include a taxi, private car, wheelchair van, or another vehicle.
    • Medicare destinations include hospital-to-home, home to another medical facility or required service, hospital to a skilled nursing, rehabilitation, or long-term acute care hospital, or dialysis services.
    • Commercial transportation must be a facility-to-facility transfer involving an acute care hospital, skilled nursing facility, rehabilitation facility, or LTAC hospital.
    Denial Risk

    Establish a qualifying stretcher-level condition

    Requests may be denied when the member does not have at least one qualifying medical condition requiring stretcher services. If bed confinement is the stated contraindication, all three bed-confined conditions must be documented.

    • The member must be unable to get up from bed without assistance.
    • The member must be unable to ambulate.
    • The member must be unable to sit in a chair or wheelchair.
    Denial Risk

    Do not omit required clinical evidence

    Prior authorization review may not be completed without clinical evidence and supporting information showing that the member meets the medical necessity criteria for non-emergent ambulance transportation.

    Policy Purpose and Scope

    Non-emergent ambulance transportation is medically necessary only when the member’s condition at the time of transport makes transportation by taxi, private car, wheelchair van, or another vehicle unsafe or contraindicated and stretcher-level ambulance services are needed. Qualifying circumstances may include inability to sit safely, severe debility or fall risk, altered consciousness, seizure risk requiring trained monitoring, paralysis, wounds requiring extreme caution, oxygen the member cannot self-manage, or safety risks requiring restraints.

    Coverage also requires an appropriate destination under the member’s coverage pathway. Medicare transportation may include hospital-to-home, home-to-medical facility or required service, hospital-to-skilled nursing, rehabilitation or long-term acute care facility, or dialysis. Commercial coverage applies to qualifying facility-to-facility transfers. If the member can safely use another form of transportation or the destination is not eligible, medical necessity is not established.

    Key Transportation Definitions

    Contraindicated alternative transportation
    DefinitionTransportation by taxi, private car, wheelchair van, or another non-ambulance vehicle is contraindicated by the member’s medical condition, and stretcher services are needed.
    Clinical basisThe member’s condition at the time of transport determines whether medical necessity is met.
    Applies toNon-emergency ambulance transportation when other transportation methods are unsafe or contraindicated.
    Bed confined
    Unable to get upThe member is unable to get up from bed without assistance.
    Unable to ambulateThe member is unable to ambulate.
    Unable to sitThe member is unable to sit in a chair or wheelchair.
    Required thresholdAll three conditions must be met when bed confinement is the condition contraindicating other transportation.
    Policy Summary
    PayerConnectiCare
    PolicyNon-Emergent Ambulance Services
    Policy CodePolicy M20200049
    Change TypeNo material change
    Effective DateSeptember 11, 2026
    Next Review DateN/A
    Key ActionSubmit clinical evidence and supporting information demonstrating that the member meets the applicable non-emergent ambulance medical necessity criteria for prior authorization.
    SourceLink
    On This Page
    Medical Necessity CriteriaProcedure CodesAuthorization and Documentation RequirementsPolicy Purpose and ScopeKey Transportation Definitions