CurrentHarvard Pilgrim Health CarePolicy N/A

Ambulance transport reimbursement

This Point32Health payment policy governs reimbursement for emergency and non-emergency ambulance transport services (ALS, BLS, wheelchair van, air ambulance) for Harvard Pilgrim and Tufts Health Plan products and applies to contracted, licensed ambulance providers.

Policy Summary

PayerHarvard Pilgrim Health Care

PolicyAmbulance transport reimbursement

Policy CodePolicy N/A

Change TypeAnnual reviewdocumentation updates (non-material)

Effective DateN/A

Next Review DateN/A

Key ActionConfirm prior authorization has been obtained as a condition of payment.

SourceLink

POLICY UPDATE CHANGES

Annual review; updated Related Policies and Resources; updated Non-Emergency Medical Necessity Documentation Submission.

Annual review; administrative edits.

Policy moved to new template; includes all lines of business.

A0998A0998 reimbursed

A0999A0999 not reimbursed

2-digitTwo-digit HCPCS required

MultipleMultiple product lines

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Coverage criteria and billing rules

Covered services, services not reimbursed, and billing/documentation rules are listed below.

ALL of the following

Covered services
- Medically necessary emergency transport
- Medically necessary transportation mileage
- Medically necessary authorized rotary wing and fixed wing air ambulance transports
  Air ambulance requires authorization
- Medically necessary authorized non-emergent medical transportation services when provided by a participating provider
Services not reimbursed
- Ambulance waiting time
- Ancillary transportation fees including parking fees and tolls, or other associated fees for lodging or meals for either the recipient or an escort, unless plan documents indicate otherwise
- Extra ambulance attendant
- Items and services included in transport reimbursement (for example: oxygen, supplies, EKG services, and drugs) — not reimbursed separately
- Ambulance mileage when no ambulance transport code was billed on the same date of service or if the transport was denied by another policy
- Non-emergent air or ground transportation to/from origins or destinations not listed in the applicable medical policy
Billing and documentation rules
- Point32Health requires two-digit HCPCS ambulance service modifiers be submitted in the first modifier field for all ambulance services; secondary modifiers must not be billed in the first position
- Bill round-trip ambulance transport on two separate lines (line one for initial transport and line two for return) unless transporting between like facilities — then bill one line with count=2
- Certain nonemergency ground ambulance modifier combinations for Tufts Health Plan Commercial products are exempt from medical necessity forms and trip notes; all other combinations for nonemergency/scheduled services are subject to retrospective review and require submission of medical necessity form and trip notes
  Providers must follow product-specific documentation rules
- Some non-emergency transportation claims for Tufts Health Together and Tufts Health RITogether members must be submitted directly to state agencies (MassHealth or RI EOHHS)
- Providers must participate in the Medicare (Title XVIII) program to be eligible to render ambulance transport services and reimbursement is subject to member benefits, eligibility, applicable authorization, and claims editing

ALL of the following

Selected HCPCS: A0998 (Ambulance response and treatment, no transport) — reimbursed for Harvard Pilgrim Commercial and Tufts Health Public Plans
Selected HCPCS: A0999 (Unlisted ambulance service) — not reimbursed

ALL of the following

Applicable referral, notification, and authorization policies may apply; providers must confirm prior authorization has been obtained as a condition of payment

ALL of the following

Reimbursement is per contracted rates and fee schedules; payment is subject to member benefits, eligibility, prior authorization, and claims editing logic

Selected HCPCS codes, modifiers, and billing details

Selected HCPCS ambulance codesHCPCS

A0998	Ambulance response and treatment, no transport- Reimbursed for Harvard Pilgrim Health Care Commercial Plans and Tufts Health Public Plans only.
A0999	Unlisted ambulance service- Not reimbursed

Billing round-trip (inv-03)

Standard billing for round-tripBill round-trip ambulance transport on two separate lines: line one for the initial transportation and line two for the return transportation.

Exception for like facilitiesWhen transport is provided between two like facilities, bill on one line with a count of two (e.g., Hospital A to Hospital B [modifier HH] and return billed as a single line with count=2).

Non-covered service submissionIf submitting a claim for non-covered services, include a medical necessity form indicating non-coverage and a valid member-signed acknowledgement of liability; claims without the form will deny as provider responsible.

Modifier codes identifying origin and destination (inv-08)

Modifier format requirementTwo-digit HCPCS ambulance service modifiers must be submitted in the first modifier field for all ambulance services; first digit = place of origin, second digit = destination.

Secondary modifiers not in first positionGM, QL, QM, QN (and other listed secondary modifiers) are considered secondary and must not be billed in the first modifier position.

Prior authorization, submission, and documentation requirements

Prior Authorization

Confirm prior authorization/notification as condition of payment

Applicable Point32Health referral, notification, and authorization policies may apply. Certain procedures, items and/or services may require referral and/or prior authorization. While you may not be the provider responsible for obtaining prior authorization, as a condition of payment you must confirm that prior authorization has been obtained.

Documentation Required

Tufts Commercial: submit medical necessity form and trip notes unless exempt

For Tufts Health Plan Commercial products, nonemergency ground ambulance claims billed with origin/destination modifier combinations DH, EH, GH, HD, HG, HH, HJ, JH, NR, PH, RH, or RN are exempt from medical necessity forms and trip notes. All other modifier combinations for nonemergency/scheduled ground transport are subject to retrospective review and require submission of a completed medical necessity form and trip notes (when applicable).

Exempt modifier combinations: DH, EH, GH, HD, HG, HH, HJ, JH, NR, PH, RH, RN
If not exempt, submit completed medical necessity form and trip notes (when applicable)
Medical necessity forms may be those used by the ambulance provider
Fax medical necessity forms to Tufts Health Plan only when financial responsibility resides with THP Commercial Plan

Documentation Required

Submit certain Tufts state-plan claims directly to MassHealth or RI EOHHS

Some non-emergency transportation claims for Tufts Health Together and Tufts Health RITogether members must be submitted directly to the state agencies (MassHealth or RI EOHHS). Providers must refer to the applicable Massachusetts and Rhode Island resources to determine coverage and claims submission requirements.

OpenPayer

Ambulance transport reimbursement

Coverage rules and reimbursement criteria

Selected HCPCS codes, modifiers, and billing details

Prior authorization, submission, and documentation requirements

Key definitions

Policy change history