CurrentGeisinger Health PlanPolicy MP017
Ambulance Transport Service
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This policy defines coverage, medical necessity criteria, and requirements (including prior authorization) for ambulance transport services provided to Geisinger Health Plan members across its lines of business.
Policy Summary
PayerGeisinger Health Plan
PolicyAmbulance Transport Service
Policy CodePolicy MP017
Change TypeNo material changes
Effective Date
Next Review Date
Key ActionObtain prior authorization from a Plan Medical Director or designee for non-emergency ambulance transports and for requests to upgrade level of service (BLS→ALS or ALS→SCT).
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
Non-EmergencyPrior authorization requirement
BLS/ALS/SCTService levels defined
Prior approvalLevel upgrade requests
Non-covered scenariosExclusions
Coverage Criteria and Service Rules
inv-01: Coverage Criteria and Conditions
Covered when ALL of the following conditions are met:
Ambulance transport is covered when the member's medical condition is such that any other method of transportation would endanger the member's health.
Examples of clinical indications (one or more):
- Requires restraints to prevent harm and/or injury to self or others.
- Requires cardiac or hemodynamic monitoring en route.
- Requires continuous IV therapy en route.
- Requires advanced airway management (e.g., ventilator dependent, apnea monitor, deep suctioning).
- Must remain immobile because of a fracture or possibility of fracture.
- Requires continuous oxygen monitoring by trained medical personnel.
Non-emergency ambulance transport requires prior authorization by a Plan Medical Director or designee; requests for level-of-service upgrades (BLS→ALS or ALS→SCT) require prior approval.
Covered services are provided in accordance with the member's benefit documents (ground ambulance transport per benefit description).
Medicaid-specific constraint (applies to Medicaid business segment):
- Coverage for ambulance transportation is limited to transport to the member's home or to the nearest appropriate medical facility only when the patient's condition absolutely precludes another method of transportation.
- Transport to a nonhospital drug and alcohol detoxification or rehabilitation facility from a hospital may be covered when the recipient presents to the hospital for inpatient drug and alcohol treatment and the hospital has determined inpatient services are not medically necessary and criteria are met.
Paramedic intercept (non-emergency):
- Considered medically necessary when ALS service is required but unavailable and a BLS ambulance service is dispatched.
- Considered medically necessary when BLS transport is planned but the member becomes medically unstable during transport and requires services beyond the scope of BLS.
If some other means of transportation (e.g., wheelchair van, stretcher van, public transportation) could be utilized without endangering the member's health, ambulance transportation is not medically necessary.
inv-02: Ambulance coverage criteria and rules
Rules, service-level definitions, limitations, exclusions, and business-segment notes that govern ambulance coverage:
Covered services: Ground ambulance transport services are provided in accordance with the member's benefit documents.
BLS services include:
- Oxygen administration (nasal cannula or mask).
- Spinal immobilization.
- Pulse oximetry when approved by the agency's medical director.
- Soft restraints with local medical command approval.
- Assistance with member self-administration of a drug.
- Member uses an automatic or semi-automatic defibrillator.
ALS services include:
- Drug administration.
- Electrocardiography (basic or 12-lead).
- IV initiation or maintenance.
- Ventilator monitoring or artificial ventilation.
- Paramedic assessment.
- Tracheal monitoring or deep suctioning.
- Administration of blood or blood products.
- Pulse oximetry/CPAP when member's condition presents a likelihood that intervention will be necessary.
SCT medical necessity and staffing:
- SCT is medically necessary for inter-facility transport of a critically ill member when services beyond EMT-Paramedic scope are required.
- Transport must be staffed by at least one of: physician, physician assistant, advanced practice nurse, registered nurse, respiratory therapist, or critical care paramedic.
- Requests for level of service upgrades from BLS to ALS, or ALS to SCT require prior approval.
Paramedic intercept (non-emergency):
- Medically necessary when ALS is required but unavailable and BLS is dispatched.
- Also medically necessary when a member becomes unstable during planned BLS transport and requires services beyond BLS scope.
Limitations - provider and transport requirements:
- Ambulance providers must comply with applicable local, state and federal laws and hold appropriate licenses and permits.
- Use of air or sea ambulance follows Medical Management policy #25 or at the discretion of the Plan Medical Director.
Exclusions / non-covered scenarios (one or more):
- Non-emergency ambulance transportation is non-covered if the services needed could be safely and effectively provided in the residence.
- Ambulance transportation primarily for convenience is not covered.
- If member is legally pronounced dead before ambulance is called, services are not covered.
- If pronounced dead after ambulance is called but before arrival, services will be considered BLS level.
- If pronounced dead after being loaded into the ambulance, coverage follows rules as if member had not died.
- Experimental, investigational or unproven services are excluded per MP015 and this policy does not expand coverage beyond member certificate exclusions.
Joint response / Medicare billing note:
- For BLS/ALS joint responses, if a BLS entity transports and an ALS entity provides an ALS intervention, the BLS supplier may bill the ALS rate only if a prior written agreement exists between entities; absent such agreement Medicare payments follow CMS rules and ALS entity services may not be covered for Medicare beneficiaries.
Business-segment and administrative notes:
- Medicaid: any requests that do not meet PARP criteria may be evaluated case-by-case; Medicaid coverage limited as specified (see Medicaid-specific node).
- Line-of-business eligibility and contract-specific benefits, limitations and exclusions supersede this policy (see member benefit documents).
- Prior authorization requirements and additional prior approval processes are available on the Geisinger prior authorization webpage; non-emergency transports require prior authorization by a Plan Medical Director or designee.
Providers must ensure documentation supports medical necessity, level of service, and any prior authorization or upgrade approvals to justify billing and reimbursement.
Coding and Line-of-Business Notes
Inventory placeholder — no codesmixed
| No codes listed |
Selected ambulance HCPCS/CPT codes (informational)HCPCS
| A0130 | Nonemergency transportation: mini-bus, mountain area transports, or other transportation systems |
| A0160 | Nonemergency transportation: wheelchair van |
| A0170 | Nonemergency transportation: per mile - caseworker or social worker |
| A0180 | Transportation ancillary: parking fees, tolls, other |
| A0190 | Nonemergency transportation: ancillary: lodgingrecipient |
| A0200 | transportation: ancillary: lodging, escort |
| A0210 | Nonemergency transportation: ancillary: meals |
| A0225 | Ambulance service, neonatal transport |
| A0380 | BLS mileage (per mile) |
| A0390 | ALS mileage (per mile) |
1–10 of 25
1/3
Misc coding notes
Example HCPCS/CPT codesA0426, A0427, A0428, A0429, A0434, A0998
Coding contextCodes listed are informational examples associated with ambulance transport services (nonemergency and specialty codes).
No exhaustive code setPolicy provides selected example codes; providers must reference applicable coding manuals and payer billing guidance for complete code lists.
Line-of-business override
ApplicabilityEligibility and contract-specific benefits, limitations and/or exclusions will apply.
PrecedenceLine-of-business benefit documents supersede this policy.
Medicare caveatFor Medicare, applicable LCDs and NCDs will supersede this policy.
PA MedicaidFor PA Medicaid business segment, this policy applies as written unless other PARP criteria apply.
Prior Authorization and Provider Requirements
Prior Authorization
Prior authorization required for non-emergency ambulance transport
Non-emergency ambulance transport requires prior authorization and medical necessity must be demonstrated; prior authorization is issued by a Plan Medical Director or designee.
- Ambulance transport is covered only when the member's condition is such that any other method of transportation would endanger the member's health.
- Examples of justifying conditions include need for restraints, cardiac/hemodynamic monitoring en route, continuous IV therapy, advanced airway management, immobilization for fracture, or continuous oxygen monitoring by trained personnel.
Prior Authorization
Prior approval required for service-level upgrades (BLS→ALS, ALS→SCT)
Requests to upgrade the level of service (BLS→ALS or ALS→SCT) require prior approval before the higher-level transport is provided.
- SCT is medically necessary only when inter-facility transport requires care beyond EMT‑Paramedic scope and must be staffed by an approved clinician (physician, PA, APN, RN, RT, or critical care paramedic).
- ALS services include drug administration, ECG, IV initiation/maintenance, ventilator monitoring/artificial ventilation, paramedic assessment, tracheal monitoring/deep suctioning, and administration of blood or blood products.
Documentation Required
Where to find and request prior authorization
Prior authorization and/or pre-certification requirements may apply; providers should consult Geisinger’s prior authorization webpage and the member's contract-specific benefit document for current requirements.
- Precertification lists are available in the member's contract-specific benefit document.
- Prior authorization requirements and where to request them: https://www.geisinger.org/health-plan/providers/ghp-clinical-policies
Definitions and Service Level Terms
Medical Necessity
DefinitionMedical Necessity: Covered services that are appropriate for the member's symptoms/diagnosis, provided for diagnosis and direct care, in accordance with current standards of good medical treatment, not primarily for convenience, and the most appropriate level of service that can safely be provided.
Inpatient applicationWhen applied to hospitalization, member requires acute inpatient care and cannot receive safe/adequate care as an outpatient.
Excludes convenienceServices provided primarily for the convenience of the member or provider are not medically necessary.
Policy maintenance terms
AttachmentA supporting document developed and maintained by the policy writer or department requiring/authoring the policy.
ExhibitA supporting document developed and maintained in a department other than the department requiring/authoring the policy.
Devised / Revised / ReviewedDevised = date policy implemented; Revised = date of every revision (including typographical); Reviewed = date documenting annual review when no revisions necessary.
Basic Life Support (BLS)
Scope of BLSBasic Life Support (BLS) ambulance transport provides oxygen administration, spinal immobilization, pulse oximetry (when approved), soft restraints (with local medical command approval), assistance with member self-administration of drug, and member use of an automatic or semi-automatic defibrillator.
Typical settingBLS is intended for stabilization and basic supportive care during transport.
Authorization noteRequests to upgrade level of service from BLS to ALS require prior approval when clinically indicated.
Advanced Life Support (ALS)
Scope of ALSAdvanced Life Support (ALS) ambulance transport provides drug administration, electrocardiography (basic or 12-lead), IV initiation/maintenance, ventilator monitoring/artificial ventilation, paramedic assessment, tracheal monitoring/deep suctioning, and administration of blood or blood products.
When usedALS is used when member requires interventions beyond BLS capabilities during transport.
Upgrade requirementRequests to upgrade from ALS to SCT require prior approval when clinically indicated.
Specialty Care Transport (SCT)
DefinitionSpecialty Care Transport (SCT) is inter-facility transport of a critically ill member that requires services beyond the scope of an EMT-Paramedic and must be staffed by at least one of: physician, physician assistant, advanced practice nurse, registered nurse, respiratory therapist, or critical care paramedic.
Use caseAppropriate for critically ill inter-facility transports needing higher-level staffing and care not deliverable by standard ALS.
Prior approvalRequests to upgrade from ALS to SCT require prior approval.
BLS/ALS Joint Response billing
Joint response billing ruleWhen a BLS entity transports and an ALS entity provides an ALS intervention, the BLS supplier may bill the ALS rate only if a prior written agreement between the BLS and ALS entities exists before claim submission.
Absent agreementIf no prior written agreement exists, only the BLS level of payment may be made and ALS entity services are not covered for Medicare beneficiaries; beneficiary may be liable for ALS services beyond BLS scope.
DocumentationProviders may be required to provide a copy of the agreement or attestation to their A/B MAC upon request.
Policy Summary
PayerGeisinger Health Plan
PolicyAmbulance Transport Service
Policy CodePolicy MP017
Change TypeNo material changes
Effective Date
Next Review Date
Key ActionObtain prior authorization from a Plan Medical Director or designee for non-emergency ambulance transports and for requests to upgrade level of service (BLS→ALS or ALS→SCT).
SourceLink
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