CurrentEmpire BluecrossPolicy C-19001

Ambulance Transportation Reimbursement

Defines Anthem/Empire BlueCross commercial reimbursement rules for ambulance transport (ground and air), associated services, supplies, and billing requirements for covered members.

Policy Summary

PayerEmpire Bluecross

PolicyAmbulance Transportation Reimbursement

Policy CodePolicy C-19001

Change TypeNo material change

Effective DateJun 1, 2024

Next Review Date

Key ActionServices must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis; follow state of residence rules.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

origin & destination modifiers requiredOrigin/destination modifiers required

base rate per tripBase rate reimbursement

response & treat reimbursableResponse & treat reimbursable

non-reimbursable listExtensive non-reimbursable list

modifier X destination-only updateModifier X update

Ambulance Coverage Criteria and Exclusions

Policy Summary

PayerEmpire Bluecross

PolicyAmbulance Transportation Reimbursement

Policy CodePolicy C-19001

Change TypeNo material change

Effective DateJun 1, 2024

Next Review Date

Key ActionServices must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis; follow state of residence rules.

SourceLink

On This Page

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.

Ambulance coverage criteria and exclusions

Coverage determinations and exclusions for ambulance services

ALL of the following

Medically necessary transport to the nearest facility equipped to treat the member (reimbursement based on ambulance base rate per trip by level of care)
Claims for transportation services must be billed with origin and destination modifiers, or the claim will be denied
Equipment and supplies are included in the ambulance base rate (disposable/first aid supplies, oxygen, reusable devices/equipment, intravenous (IV) drugs, ambulance personnel service)
ALL of the following
- Mileage
- Member consents to evaluation and treatment
- Member does not desire transport to an emergency department for evaluation
- After evaluation, medic and member agree there is not a medical emergency
- Member is stable for referral to the member's physician or other community resource
- Member has the ability (mental capacity, transportation resources) to obtain assistance and medically indicated follow-up

ANY of the following

Transport for reasons other than medical care
Non-ambulance medical transport service (NEMT) where applicable exclusions apply
Mileage when the transport service has been denied or is not covered
Where other means of transportation could be used without endangering the member's health (transport where other means could be used safely)
Separate reimbursement for services/items included in the ambulance base rate
Both BLS and ALS billed when ALS services are provided

ALL of the following

Reimbursement is based on the ambulance base rate per trip in accordance with the appropriate level of care provided to the member
Items and services listed as included in the base rate must not be billed separately

Ambulance Coding, Modifiers, and Reimbursement

Ambulance CPT/HCPCS/Revenue Codesmixed

A0000-A0999	Ambulance HCPCS temporary code range (examples vary by payer)
A0425	Ground mileage (per mile)
A0426	Ambulance service, advanced life support, non-emergency transport, level 1 (ALS1)
A0428	Ambulance service, basic life support, non-emergency transport (BLS)
A0998	Non-emergency transportation, other (when applicable)
99070	Supplies and materials (when separately billable)
045x	Revenue codes for ambulance services (e.g., 0450, 0451, 0452 series)

Billing Code Systemsmixed

CPT	Current Procedural Terminology — use for procedure-level services when applicable
HCPCS	Healthcare Common Procedure Coding System — primary system for ambulance codes (A-codes) and modifiers
Revenue	Hospital/facility revenue codes (e.g., 045x) for facility billing
Modifier	Use of Origin/Destination and other ambulance modifiers required on claims

Ambulance Modifiers (required/used for origin, destination, and other billing rules)Modifier

D	Diagnostic or therapeutic site — origin/destination modifier (other than P or H)
E	Residential, domiciliary, custodial facility — origin/destination modifier
G	Hospital-based dialysis facility — origin/destination modifier
H	Hospital (inpatient or outpatient) — origin/destination modifier
?	Site of transfer between types of ambulances — origin/destination modifier (placeholder from source)
N	Skilled Nursing Facility (SNF), including swing-bed — origin/destination modifier
P	Physician's office, including HMO nonhospital facility, clinic — origin/destination modifier
R	Private residence — origin/destination modifier
S	Scene of accident or acute event — origin/destination modifier
X	Intermediate stop at physician's office en route to hospital — destination modifier only (second position)

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Authorization and Medical Necessity Requirements

Note

Authorization, medical necessity, billing, and denial risk for ambulance services

Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis and to the member's state of residence; claims must follow proper billing and submission guidelines and be supported in the medical record. Claims for ambulance transportation must be billed with origin and destination modifiers or the claim will be denied. Ambulance response-and-treat with no transport is reimbursable only when all listed criteria are met (mileage, member consent to evaluation/treatment, member declines ED transport, medic and member agree no emergency, member stable for referral, member able to obtain follow-up).

Obtain and document authorization/medical necessity consistent with the procedure, diagnosis, and member's state of residence (medical record must support billed services).
Use industry-standard CPT, HCPCS, and/or revenue codes on claims and ensure documentation supports the codes billed.
Include origin and destination modifiers on all ambulance transport claims — claims without these modifiers will be denied.
For response-and-treat without transport, document that all criteria are met: mileage, member consent to evaluation/treatment, member declines ED transport, medic and member agree there is not a medical emergency, member is stable for referral, and member can obtain follow-up.

Key Terms and Definitions

Key terms — ALS, BLS and related definitions

Advanced Life Support (ALS)Invasive services provided by personnel trained as Emergency Medical Technicians (EMT) (intermediate or paramedic) in conjunction with applicable state laws.

Basic Life Support (BLS)Non-invasive services provided by personnel trained as EMTs (basic) in conjunction with applicable state laws.

Air AmbulanceAn equipped and staffed aircraft necessary to rapidly transport a member to the nearest appropriate facility when ground transport would endanger the member's health; includes rotary-wing and fixed-wing aircraft.

Ambulance ServicesThe medically necessary transport of a member by medically skilled personnel to the nearest appropriate facility equipped to provide care for the member's injury and/or illness; services delineated as BLS or ALS and as emergency or non-emergency.

Medical Transport Service (NEMT)Transport of a member by non-medically skilled personnel (e.g., ambulette/medi-van, wheelchair van, taxi, mini-bus, public transportation) to receive covered services.