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    v1.0.28
    OpenPayerPolicy UpdatesEmergency & Medical TransportationDevoted Health Ambulance Coverage | OpenPayer
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    CurrentDevoted HealthPolicy UMGT.CL.0002

    Non-Emergent Ambulance Transportation

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    This policy governs coverage and reimbursement for non-emergent ambulance transportation for members enrolled in all Devoted Health plans. It establishes medical-necessity, physician-order, documentation, destination, and exclusion requirements for ambulance services.

    Policy Summary
    PayerDevoted Health
    PolicyNon-Emergent Ambulance Transportation
    Policy CodePolicy N/A
    Change TypeMaterial clarification and documentation update
    Effective DateFeb 20, 2026
    Next Review DateN/A
    Key ActionObtain the physician's written order for non-emergent transport before submitting the claim.
    SourceLink
    POLICY UPDATE CHANGES

    The policy adds a clarification that facility-to-facility ambulance transport does not require prior authorization.

    The physician written order for non-emergent ambulance transport must be obtained before claim submission.

    The policy history records clarified language regarding medical-necessity criteria.

    AllPlans covered
    2Pre-claim requirements

    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.

    10Applicable codes
    4Stretcher-transport examples
    No PAFacility-to-facility prior authorization

    Non-Emergent Ambulance Coverage

    Covered Non-Emergent Ambulance Transport

    Covered when the medical-necessity and documentation requirements are met:

    Medical necessity and destination: The member's condition makes use of any other transportation method contraindicated, the need is certified by the physician responsible for the member's care, and the transport is to a specific covered destination, including transport between covered facilities.

    The ambulance provider or supplier must meet all coverage criteria.

    Required documentation: A physician's written order for transport is obtained before claim submission, and the rationale for the condition and supporting medical-necessity documentation are provided.Before claim submission

    Supporting records may include an emergency room report or relevant hospital record.

    Examples supporting stretcher transport: The member has contractures causing non-ambulatory status and inability to sit; severe generalized weakness; severe vertigo causing inability to remain upright; or lower-extremity immobility, such as a spica cast, fixed hip joints, or lower-extremity paralysis, preventing wheelchair transport.

    These are examples of conditions supporting stretcher transport. Bed confinement alone is neither sufficient nor necessary to establish coverage.

    Special Transport Circumstances

    Additional transport circumstances are evaluated as follows:

    Combined ground and air ambulance: Ground ambulance and air ambulance services may both be reimbursed when both services are medically necessary.Both services medically necessary

    Each service remains subject to applicable coverage criteria.

    Residence-to-provider-office transport: Requests for non-emergent ambulance transport from a member's residence to a provider's office are evaluated case by case.Case-by-case review

    The policy also identifies physician-office and physician-directed-clinic transport as non-covered under Medicare guidance.

    Transport is excluded when another means of transportation, such as a private car or wheelchair van, could be used safely without endangering the member, whether or not that alternative transportation is actually available. Coverage is also excluded when the service could have been safely and effectively provided at the point of origin, including in the member’s home or originating skilled nursing facility, or when the transport is for an excluded service.

    Under Medicare guidance, ambulance service to a physician’s office or a physician-directed clinic is not covered.

    Ambulance transport is not medically necessary when the member can safely use another transportation method, regardless of whether that alternative is actually available.

    Bed confinement alone is neither required nor sufficient to establish medical necessity for ambulance transport. It is one factor in assessing whether the member’s overall condition makes other transportation methods contraindicated.

    Applicable Ambulance Codes

    Covered HCPCS CodesHCPCSCovered
    A0425GROUND MILEAGE, PER STATUTE MILE
    A0426AMBULANCE SERVICE, ADVANCED LIFE SUPPORT, NON-EMERGENCY TRANSPORT, LEVEL 1 (ALS 1)
    A0428AMBULANCE SERVICE, BASIC LIFE SUPPORT, NON-EMERGENCY TRANSPORT, (BLS)
    A0430AMBULANCE SERVICE, CONVENTIONAL AIR SERVICES, TRANSPORT, ONE WAY (FIXED WING)
    A0431AMBULANCE SERVICE, CONVENTIONAL AIR SERVICES, TRANSPORT, ONE WAY (ROTARY WING)
    A0432PARAMEDIC INTERCEPT (PI), RURAL AREA, TRANSPORT FURNISHED BY A VOLUNTEER AMBULANCE COMPANY WHICH IS PROHIBITED BY STATE LAW FROM BILLING THIRD PARTY PAYERS
    A0433ADVANCED LIFE SUPPORT, LEVEL 2 (ALS 2)
    A0434SPECIALTY CARE TRANSPORT (SCT)
    A0435FIXED WING AIR MILEAGE, PER STATUTE MILE
    A0436ROTARY WING AIR MILEAGE, PER STATUTE MILE

    Authorization, Documentation, and Denial Risks

    Prior Authorization

    Facility-to-Facility Transport Authorization

    No prior authorization is required for facility-to-facility ambulance transport. All other applicable coverage, medical-necessity, documentation, and provider requirements remain in effect.

    Documentation Required

    Written Order Required Before Claim Submission

    Obtain the physician's written order for non-emergent ambulance transport before submitting the claim.

    Documentation Required

    Support Medical Necessity

    Document the member's condition supporting ambulance transport and submit documentation that establishes medical necessity.

    Policy Context

    Non-emergent ambulance transport may be covered when the member’s condition makes use of any other transportation method contraindicated and the need is certified by the physician responsible for the member’s care. Coverage applies to transport to specific covered destinations, including between covered facilities, when the medical-necessity and documentation requirements are met. Clinical circumstances that may support stretcher transport include contractures that prevent sitting, severe generalized weakness, severe vertigo that prevents an upright posture, or lower-extremity immobility that prevents wheelchair transport.

    Key Terms and Acronyms

    Bed confinement
    DefinitionA condition in which the member is restricted to bed, cannot be moved by wheelchair, and must be moved by stretcher.
    Medical-necessity relationshipBed confinement is one element of the member’s overall condition when determining whether transportation other than an ambulance is contraindicated.
    Coverage determinationBed confinement alone is neither sufficient nor necessary to establish coverage for ambulance transport.
    CMS
    AbbreviationCMS
    Full nameCenters for Medicare and Medicaid Services
    Definition
    Policy Summary
    PayerDevoted Health
    PolicyNon-Emergent Ambulance Transportation
    Policy CodePolicy N/A
    Change TypeMaterial clarification and documentation update
    Effective DateFeb 20, 2026
    Next Review DateN/A
    Key ActionObtain the physician's written order for non-emergent transport before submitting the claim.
    SourceLink
    On This Page
    Non-Emergent Ambulance CoverageApplicable Ambulance CodesAuthorization, Documentation, and Denial RisksPolicy ContextKey Terms and Acronyms
  1. Include the rationale, such as bed confinement or another clinically significant condition.
  2. Submit supporting records when applicable, such as an emergency room report or relevant hospital record.
    3. Denial Risk

    Safe Alternative Transportation Available

    Deny ambulance payment when another means of transportation could be used without endangering the member's health, whether or not that alternative transportation is actually available.

    • Consider alternatives such as a private car or wheelchair van.
    Denial Risk

    Service Available at Point of Origin

    Deny transport when the service could have been safely and effectively provided at the point of origin, even if the member could only have traveled by ambulance.

    • Examples include transport from a residence for a service that could be performed more economically at home.
    • For an SNF resident, this includes transport to a hospital or another SNF for a service that could be performed more economically at the first SNF.
    Denial Risk

    Transport for Excluded Service

    Transportation to receive an excluded service is not covered, even when ambulance transport is the member's only feasible means of travel.

    • Example: transportation for a routine dental examination.
    Denial Risk

    Return Transportation to the United States

    Transportation back to the United States is not covered unless the nearest hospital is within the United States.

    Denial Risk

    Physician Office or Directed Clinic Transport

    Medicare does not cover ambulance service to a physician's office or a physician-directed clinic.

    Billing Rule

    Provider Must Satisfy All Criteria

    Payment requires the ambulance provider or supplier to meet every applicable coverage criterion.

    • Non-emergent ambulance transport must satisfy the applicable medical-necessity and documentation requirements.
    • When both ground and air ambulance services are medically necessary, both may be reimbursed.
    • Transport from a member's residence to a provider's office is evaluated case by case.
    Centers for Medicare and Medicaid Services.
    LCD
    AbbreviationLCD
    Full nameLocal Coverage Determinations
    DefinitionLocal Coverage Determinations.
    MCD
    AbbreviationMCD
    Full nameCMS Medicare Coverage Database
    DefinitionCMS Medicare Coverage Database.
    NCD
    AbbreviationNCD
    Full nameNational Coverage Determination
    DefinitionNational Coverage Determination.
    UM
    AbbreviationUM
    Full nameUtilization Management
    DefinitionUtilization Management.