ModifiedExcellus Health Plan IncPolicy 10.01.07

Ambulance: Land/Ground

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This policy governs medical-necessity coverage criteria for emergency and non-emergent land/ground ambulance transportation, subject to New York State mandates and the member's contract.

Policy Summary

PayerExcellus Health Plan Inc

PolicyAmbulance: Land/Ground

Policy CodePolicy 10.01.07

Change TypeModified

Effective DateMarch 19, 2026

Next Review DateMarch 1, 2027

Key ActionDocument the patient's condition and why any other form of transportation would be medically contraindicated.

SourceLink

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ModifiedExcellus Health Plan IncPolicy 10.01.07

Ambulance: Land/Ground

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This policy governs medical-necessity coverage criteria for emergency and non-emergent land/ground ambulance transportation, subject to New York State mandates and the member's contract.

Policy Summary

PayerExcellus Health Plan Inc

PolicyAmbulance: Land/Ground

Policy CodePolicy 10.01.07

Change TypeModified

Effective DateMarch 19, 2026

Next Review DateMarch 1, 2027

Key ActionDocument the patient's condition and why any other form of transportation would be medically contraindicated.

SourceLink

POLICY UPDATE CHANGES

Criteria for urgent ambulance transportation were removed during the March 19, 2026 annual review.

Criteria addressing cost effectiveness were removed during the March 19, 2026 annual review.

2Transport categories addressed

4Emergency ambulance criteria

4Non-emergent qualifying indications

1Non-medically necessary category

2Criteria topics removed

Medical Necessity and Coverage Criteria

Emergency Land/Ground Ambulance Transportation

Emergency land/ground ambulance transportation is considered medically appropriate, when the New York State (NYS) mandate does not apply, when ALL of the following criteria are met:

ALL of the following

The services are provided by an ambulance service issued a certificate under the NYS Public Health Law.
The ambulance has the necessary patient-care equipment and supplies.
The individual's condition is such that any other form of transportation would be medically contraindicated.
The individual is transported to the nearest hospital with the appropriate facilities for treatment of the patient's illness or injury.

Non-Emergent Medical Transport

Non-emergent ambulance services for medical transport are considered medically appropriate when ALL baseline criteria are met and at least ONE qualifying indication applies:

ALL baseline criteria

The services are provided by an ambulance service issued a certificate under the NYS Public Health Law.
The ambulance has the necessary patient-care equipment and supplies.
The individual's condition is such that any other form of transportation would be medically contraindicated.
The provider of the specialized service is the nearest facility with the required capabilities.
At least ONE of the following indications
- Transport is from a non-participating hospital to a participating hospital.
- Transport is to a hospital that provides a higher level of care that was not available at the original hospital.

Emergency Ground Ambulance Coverage Under the NYS Mandate

Under the NYS mandate, pre-hospital emergency services and ground ambulance transportation are covered when a prudent layperson possessing an average knowledge of medicine and health could reasonably expect that absence of the transportation would result in a serious condition. The mandate applies to major medical or similar comprehensive-type contracts, including HMO and Child Health Plus contracts.

Mandated emergency ground ambulance coverage

The transportation is provided by an ambulance service certified under the NYS Public Health Law.
A prudent layperson could reasonably expect that without the transportation there would be:
- Serious jeopardy to the health of the person afflicted, or, for a pregnant woman, to the health of the woman or her unborn child; for a behavioral condition, serious jeopardy to the health of the person or others.
- Serious impairment to the person's bodily function.

Covered Transport Purposes

Ambulance and medical transport may be covered for medically necessary emergency or non-emergent purposes when the applicable coverage criteria are met.

Covered transport purposes

Emergency transportation of an individual to the nearest hospital with the appropriate facilities for treatment of the individual's illness or injury.
Non-emergent medical transport of a registered hospital inpatient to another location to obtain medically necessary, specialized diagnostic or therapeutic services.

Elective or convenience ambulance transportation is considered not medically necessary, including transportation requested because of patient or family preference or transportation from one facility to another facility within the same health care system for capacity management.

Non-emergent medical transport of a bed-confined patient is ineligible for coverage as ambulance transportation when specialized medical services during transport are not necessary. Alternative transportation such as an ambulette, van, or taxicab is generally excluded by contract.

When the NYS mandate does not apply to ambulance transportation, contractual distance restrictions may apply. Refer to the member's subscriber contract for specific limitations.

Bed-confined non-emergent transport is not eligible as ambulance transportation when specialized medical services during transport are unnecessary; transportation by ambulette, van, or taxicab is generally excluded by contract.

Transportation services using vehicles that are not equipped and certified under the New York Public Health Law to provide emergency medical services, including an ambulette, van, or taxicab, are ineligible for coverage because they do not provide medical care or monitoring during transportation.

Transportation Exclusions Under the NYS Mandate

The NYS mandate does not require coverage for the following transportation types:

Excluded transportation types

Air ambulance transportation.
Ambulance transportation between hospitals or other health care facilities.

Ambulance services for deceased members may be eligible when the patient is legally pronounced dead after the ambulance is called but before pickup or while en route to the hospital. Services are ineligible when the patient is pronounced dead before the ambulance is called.

Mileage beyond the closest appropriate facility is non-covered ambulance mileage.

Services are contract dependent. If a product does not cover a service, medical policy criteria do not apply. When a commercial, Medicaid, or Medicare product covers the service and no applicable state, national, or local coverage criteria govern, the medical policy criteria apply to the benefit.

Elective or convenience ambulance transportation, including transportation based on patient or family preference or movement between facilities within the same health care system for capacity management, is not medically necessary.

Bed-confined non-emergent transport is not eligible as ambulance transportation when specialized medical services during transport are unnecessary.

Coding and Billing Information

HCPCS CodesHCPCS

A0021	Ambulance service, outside state per mile, transport (Medicaid only)
A0080-A0130	Non-emergency transportation; ground vehicle (code range)
A0160-A0210	Non-emergency transportation (code range)
A0225	Ambulance service, neonatal transport, base rate, emergency transport, one way
A0380	BLS mileage (per mile)
A0382-A0384	BLS disposable supplies (code range)
A0390	ALS mileage (per mile)
A0392-A0398	ALS disposable supplies (code range)
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

1–10 of 26

1/3

CPT CodesCPT

No codes listed

ICD10 CodesICD-10

No codes listed

Authorization, Documentation, and Denial Risks

Prior Authorization

Interfacility Transfer Authorization Is Contract-Dependent

Verify the member's subscriber contract before an interfacility transfer. Prior authorization is contract-dependent and must be obtained before transfer when the contract requires it; some contracts exclude transfers between healthcare facilities.

Prior Authorization

Emergency Department Acceptance Does Not Remove Authorization Requirements

Accepting a registered inpatient through the emergency department does not eliminate the requirement for prior authorization when the member contract requires authorization for the inpatient admission or transfer.

Documentation Required

Document Medical Necessity for Ambulance-Level Transport

Policy Background

Ambulance transportation is appropriate when the patient's condition requires ambulance-level care or makes other transportation medically unsafe. Emergency transport is directed to the nearest hospital with appropriate treatment facilities, while non-emergent transport requires a qualifying transfer indication and a facility with the necessary capabilities.

Key Terms

Elective or convenience ambulance transportation

DefinitionTransportation based on patient or patient's family desire.

ExampleTransportation from one facility to another facility within the same health care system for capacity management.

Policy statusConsidered not medically necessary.

Non-ambulance transportation

DefinitionTransportation of a bed-confined patient when specialized medical services during transport are not necessary.

ClassificationThis is treated as non-ambulance transportation.

Examples

Policy Summary

PayerExcellus Health Plan Inc

PolicyAmbulance: Land/Ground

Policy CodePolicy 10.01.07

Change TypeModified

Effective DateMarch 19, 2026

Next Review DateMarch 1, 2027

Key ActionDocument the patient's condition and why any other form of transportation would be medically contraindicated.

SourceLink

On This Page

The individual has been approved for interfacility transfer under CMP #11.01.18, Interfacility Transfer of a Registered Patient.

Transport is from an acute care facility to a sub-acute setting.

Serious dysfunction of a bodily organ or part.

Serious disfigurement.

Document the patient's condition and why transportation by any other means would be medically contraindicated. This medical-necessity requirement applies to both emergency and non-emergent ambulance transport when the applicable criteria are being evaluated.

Documentation Required

Use and Document the Appropriate Nearest Destination

Document that the patient was transported to the nearest hospital with appropriate facilities, or that the specialized-service provider was the nearest facility with the required capabilities. A non-nearest appropriate destination creates coverage risk.

Documentation Required

Document a Qualifying Non-Emergent Indication

For non-emergent medical transport, document at least one qualifying indication: transfer from a non-participating hospital to a participating hospital; transfer to a hospital providing a higher level of care unavailable at the original hospital; an approved interfacility transfer under CMP #11.01.18; or transfer from an acute care facility to a sub-acute setting.

Denial Risk

Show That Alternative Transportation Is Medically Inappropriate

Coverage may be denied when another form of transportation would be medically appropriate. The patient's condition must establish that other transportation is medically contraindicated; inconvenience or preference alone is insufficient.

Denial Risk

Elective or Convenience Transport Is Not Medically Necessary

Do not bill elective or convenience ambulance transportation as medically necessary, including transport requested by the patient or family and movement between facilities within the same healthcare system for capacity management.

Denial Risk

Bed-Confined Patient Without Specialized Transport Needs

When a bed-confined patient does not require specialized medical services during transport, treat the service as non-ambulance transportation rather than ambulance transport. Ambulette, van, and taxicab transportation is generally excluded by contract and is ineligible for coverage under this policy.

Denial Risk

Use a Certified Ambulance Service

Confirm that the ambulance service holds the required certificate under the New York State Public Health Law. Emergency and non-emergent ambulance services provided by an uncertified service are not eligible under the applicable ambulance criteria.

Denial Risk

Verify Vehicle Certification and Specialized Transport Requirements

Non-ambulance vehicles such as ambulettes, vans, and taxicabs must not be represented as ambulance services. Vehicles that are not equipped and certified under the New York Public Health Law to provide emergency medical services are ineligible because they do not provide required medical care or monitoring during transport.

Billing Rule

Apply Contractual Distance Restrictions

When the New York State mandate does not apply, review the member's subscriber contract for applicable distance restrictions and other contractual limitations.

Denial Risk

Transport After Death

Ambulance services for a deceased member may be eligible only when the patient was legally pronounced dead after the ambulance was called, including before pickup or while en route. Services are ineligible when death was pronounced before the ambulance was called.

Denial Risk

Excluded Transportation Types

Apply the New York State mandate's transportation limitations when assessing coverage. The mandate explicitly excludes ambulance transportation between hospitals or healthcare facilities and does not require coverage of air ambulance transportation; confirm any air ambulance benefit separately under the member's contract.

Billing Rule

Mileage Beyond the Closest Appropriate Facility

Do not report mileage beyond the closest appropriate facility as covered ambulance mileage. HCPCS code A0888 identifies non-covered ambulance mileage, including miles traveled beyond the closest appropriate facility.

HCPCS A0888 — Non-covered ambulance mileage, per mile

Prior Authorization

Verify Product Benefit Coverage First

Before applying the medical policy criteria, verify that the member's specific product covers the service. Services are contract-dependent; if the product does not cover the service, the medical policy criteria do not create coverage.

Commercial products: apply policy criteria when the product covers the service.
Medicaid products: apply policy criteria when no applicable New York State Medicaid (eMedNY) criteria exist.
Medicare products: apply policy criteria when no national or local Medicare coverage decision applies; if a Medicare HMO-Dual SNP does not cover the service, refer to the Medicaid product coverage line.

Alternative transportation may include an ambulette, van, or taxicab; such transportation is generally excluded by contract.

Emergency Condition

StandardA medical or behavioral condition with acute symptoms of sufficient severity, including severe pain, for which a prudent layperson possessing an average knowledge of medicine and health could reasonably expect the absence of immediate medical attention to cause a serious consequence.

Serious jeopardyThe health of the person, a pregnant woman or unborn child, or—in a behavioral condition—the person or others could be placed in serious jeopardy.

Impairment or dysfunctionThe absence of immediate medical attention could cause serious impairment to bodily function or serious dysfunction of any body organ or part.

DisfigurementThe absence of immediate medical attention could cause serious disfigurement.

Urgent services

DefinitionA medical or behavioral condition requiring immediate attention, although the condition may not be an emergency situation.

Potential progressionThe condition has the potential to become emergent in the absence of treatment.

Care requirementImmediate attention is required even when the condition does not currently meet the emergency standard.

Non-emergent services

DefinitionServices for a medical or behavioral condition that are not considered to be of an emergent or urgent nature.

ClassificationThe condition is neither emergent nor urgent.

ExampleElective surgery.

Ambulance services

DefinitionTransportation involving assessment and administration of care to an ill or injured individual by specially trained personnel.

Vehicle requirementsTransportation occurs in specially designed and equipped vehicles.

Care environmentThe individual is transported within an appropriate, safe, and monitored environment.