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    v1.0.30
    OpenPayerPolicy UpdatesClinical/Medical PolicyHealth New England Transportation Prior Auth | Ope…
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    CurrentHealth-New-EnglandPolicy UM978POL

    Non-Emergent Transportation Medical Policy

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    Coverage and prior authorization for non-emergency ground ambulance, wheelchair van, and air ambulance transportation for Commercial and Medicare Advantage members; Medicaid non-emergency transportation is excluded under the MassHealth NEMT benefit.

    Policy Summary
    PayerHealth-New-England
    PolicyNon-Emergent Transportation Medical Policy
    Policy CodePolicy UM978POL
    Change TypeAdded coding guidance
    Effective DateNovember 1, 2026
    Last ReviewAug 1, 2025
    Next Review DateN/A
    Key ActionObtain plan-approved prior authorization for non-emergency medically necessary transportation and document it in the approved authorization.
    SourceLink
    POLICY UPDATE CHANGES

    HCPCS code A0130 for nonemergency wheelchair-van transportation was added to the coding table.

    RequiredPrior authorization
    <150 miFacility-transfer exception

    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.

    6Ground contraindications
    Not coveredCriteria not met

    Medical Necessity and Coverage Criteria

    Non-emergency ground ambulance

    Non-emergency ground ambulance services are medically necessary when all required elements are met.

    Ground ambulance criteria

    • Required service elements

      • The ambulance has the necessary equipment and supplies to address the member's needs.
      • Transportation is to and/or from medically necessary care.

    • Reason other transportation is unsafe

      • Bed confinement or medical contraindication

        • Bed confined

          • The member is unable to get out of bed without assistance, unable to ambulate, and unable to sit in a chair or wheelchair before and after transport.

        • Medical contraindications

          • The member cannot safely sit upright while seated in a wheelchair.
          • The member can tolerate a wheelchair but is medically unstable.
          • The member requires oxygen and oxygen-saturation monitoring, without a portable oxygen system, to treat hypoxemia, syncope, airway obstruction, or chest pain.
          • The member requires physical restraint during transportation or is at risk of harming themselves or others.
          • The member has a physical condition, such as a body cast or spica cast, that prevents safe transfer by another transportation method.
          • The member requires continued medical isolation precautions for an active infectious process.

      • Skilled or trained monitoring

        • The member is comatose.
        • The member requires airway monitoring.
        • The member requires cardiac monitoring.
        • The member is dependent on a ventilator.
        • The member is dependent on other enabling machines or devices.

    Wheelchair van

    Wheelchair van coverage may be approved when all criteria are met.

    Wheelchair van criteria

    • Transportation is to and/or from medically necessary care.
    • The member is unable to ambulate with or without assistance and with or without an assistive device.
    • The member is unable to safely transfer from a wheelchair to a private vehicle, with or without assistance.
    • The member requires medical transportation whenever accessing the community for any purpose and cannot be safely transported by private car or taxi.

    Non-emergency air ambulance

    Non-emergency air ambulance transportation is medically necessary when all criteria are met.

    Air ambulance criteria

    • The service is medically required due to the patient's clinical status.
    • The medical record documents that the patient cannot reasonably transport by other means because of a medical condition and requires immediate or rapid transport.
    • The transportation is directly related to inpatient hospital acute care.
    • The inpatient acute-care facility where the patient is currently admitted is not equipped to adequately treat the condition, or the patient requires transport to an inpatient acute-care facility to receive a prior approved transplant.
    • Travel by an alternate method, such as basic or advanced life-support ground or sea ambulance, would cause a clinically significant delay in receiving the required care that could potentially jeopardize the patient's health, life, or ability to regain maximum function.

    Non-urgent Medicaid transportation is not covered by HNE under this policy because it is included in the Medicaid non-emergency Medical Transportation (NEMT) benefit directly covered by MassHealth.

    HCPCS A0130, nonemergency transportation by wheelchair van, is identified as not covered by Medicare.

    Non-emergency ground and air ambulance services are considered not medically necessary when the applicable policy criteria are not met or when services are requested for any other indication.

    Coding and Authorization Parameters

    Coding GuidanceHCPCS
    A0130Nonemergency transportation: wheelchair van (Not covered by Medicare)
    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)
    A0435Fixed wing air mileage, per statute mile
    Specified facility-transfer transportation
    Distance limitUnder 150 miles
    Covered membersCommercial and Medicare members
    Hospital-to-hospital transferDoes not require prior authorization
    Hospital-to-acute rehabilitation or skilled nursing facilityDoes not require prior authorization
    Acute rehabilitation or skilled nursing facility-to-hospital transferDoes not require prior authorization

    Authorization, Documentation, and Denial Risks

    Prior Authorization

    Prior Authorization Required

    Non-emergency, medically necessary transportation for scheduled or non-scheduled medical treatment requires prior authorization approved by Health New England, and the service must be documented in the approved authorization.

    Prior Authorization

    Facility-Transfer Authorization Exception

    For Commercial and Medicare members, prior authorization is not required for transportation under 150 miles when the trip meets one of the specified facility-transfer origin and destination combinations.

    • Hospital to hospital.
    • Hospital to acute rehabilitation or skilled nursing facility.
    • Acute rehabilitation or skilled nursing facility to hospital.

    Unsupported block type: documentation

    Unsupported block type: documentation

    Unsupported block type: documentation

    Policy Scope and Context

    This policy addresses non-emergency transportation for members who require medically necessary care but cannot safely travel by private vehicle, taxi, wheelchair-accessible vehicle, or another transportation method. Coverage is based on the member’s functional limitations, medical stability, required equipment or monitoring, isolation or safety risks, and—when applicable—the clinical need for air transportation.

    Relevant Definitions

    Bed confined
    Unable to get out of bedRequires assistance
    AmbulationUnable to ambulate
    SittingUnable to sit in a chair or wheelchair
    TimingAll limitations must apply both before and after transport
    Transportation limitationBed confinement supports that safe transportation by other means is not possible
    Policy Summary
    PayerHealth-New-England
    PolicyNon-Emergent Transportation Medical Policy
    Policy CodePolicy UM978POL
    Change TypeAdded coding guidance
    Effective DateNovember 1, 2026
    Last ReviewAug 1, 2025
    Next Review DateN/A
    Key ActionObtain plan-approved prior authorization for non-emergency medically necessary transportation and document it in the approved authorization.
    SourceLink
    On This Page
    Medical Necessity and Coverage CriteriaCoding and Authorization ParametersAuthorization, Documentation, and Denial RisksPolicy Scope and ContextRelevant Definitions

    Examples include significant travel distances, natural disasters, extreme weather conditions, or other barriers to transfer.

    Denial Risk

    Criteria Not Met or Other Indication

    Non-emergency ground and air ambulance services are considered not medically necessary when the applicable policy criteria are not met or when the transportation is requested for any other indication.

    • Ensure the request directly supports a covered policy indication before seeking authorization.
    • A medical-necessity determination does not override exclusions or limitations in the member's benefit program.
    Denial Risk

    Insufficient Ground Transportation Necessity

    Ground transportation may be denied when the submitted documentation does not establish that the member requires ambulance-level or wheelchair-van transportation for medically necessary care and cannot be safely transported by another method.

    • Ground ambulance: denial risk exists when the member is not bed confined, does not have a qualifying contraindication to other transportation, or does not require the specified monitoring, equipment, or precautions.
    • Wheelchair van: denial risk exists when the member can ambulate, can safely transfer to a private vehicle, or does not require medical transportation for community access.
    Denial Risk

    Air Ambulance Criteria Not Met

    Non-emergency air ambulance transportation may be denied when air transport is not clinically required, the patient can reasonably travel by another means, or alternate transportation would not create a clinically significant delay in receiving required care.

    • All air ambulance medical-necessity criteria must be documented.
    • The request must relate directly to inpatient acute care and meet the facility, transplant, and alternate-travel-time requirements.
    Billing Rule

    Benefit or Program Exclusion

    Coverage is subject to the member's benefit program and applicable law. Medicaid non-urgent transportation is excluded from HNE coverage because it is included in the MassHealth Medicaid non-emergency medical transportation benefit; Medicare does not cover HCPCS A0130 for non-emergency wheelchair-van transportation.

    • Medicaid/BeHealthy: obtain non-emergency transportation through the MassHealth NEMT benefit.
    • HCPCS A0130: non-emergency transportation by wheelchair van; not covered by Medicare.