CurrentHealthy Blue LouisianaPolicy G-07036

Transportation Services: Ambulance and Non-Emergent Transport

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Reimbursement rules for ambulance transportation and related medical transport services, including coverage criteria, billing requirements, modifiers, base-rate inclusions, and exclusions.

Policy Summary

PayerHealthy Blue Louisiana

PolicyTransportation Services: Ambulance and Non-Emergent Transport

Policy CodePolicy N/A

Change TypeMaterial update

Effective Date05/22/2024

Next Review DateN/A

Key ActionBill transportation claims with the applicable origin and destination modifiers; claims without these modifiers may be denied.

SourceLink

POLICY UPDATE CHANGES

The policy removed ambulance base-rate reimbursement when no transportation is provided, including treatment without transport.

The policy added wait-time fees and outreach fees to the nonreimbursable services list.

The policy was revised to reference transportation submission requirements and to add modifiers explaining transportation services.

1Ambulance base rate reimbursed per trip according to the level of care provided

2Mileage is separately reimbursable from the ambulance base rate

15+Listed ambulance and medical transport exclusions

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CurrentHealthy Blue LouisianaPolicy G-07036

Transportation Services: Ambulance and Non-Emergent Transport

Customize your policy alerts

Sign up for healthybluelouisiana Policy G-07036 alerts

Get alerted when Policy G-07036 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Reimbursement rules for ambulance transportation and related medical transport services, including coverage criteria, billing requirements, modifiers, base-rate inclusions, and exclusions.

Policy Summary

PayerHealthy Blue Louisiana

PolicyTransportation Services: Ambulance and Non-Emergent Transport

Policy CodePolicy N/A

Change TypeMaterial update

Effective Date05/22/2024

Next Review DateN/A

Key ActionBill transportation claims with the applicable origin and destination modifiers; claims without these modifiers may be denied.

SourceLink

POLICY UPDATE CHANGES

The policy removed ambulance base-rate reimbursement when no transportation is provided, including treatment without transport.

The policy added wait-time fees and outreach fees to the nonreimbursable services list.

The policy was revised to reference transportation submission requirements and to add modifiers explaining transportation services.

1Ambulance base rate reimbursed per trip according to the level of care provided

2Mileage is separately reimbursable from the ambulance base rate

15+Listed ambulance and medical transport exclusions

ModifiersRequired claim billing elements for transportation services

Nearest facilityTransport destination standard for reimbursable ambulance services

Ambulance and Medical Transport Coverage

Ambulance reimbursement criteria

Ambulance transportation and associated services may be reimbursed when all of the following criteria are met:

ALL of the following

Transport is to or from a covered service or another service mandated by contract.
Applicable authorization and medical-necessity requirements are met.
Transport is to the nearest facility equipped to treat the member.
The claim uses the appropriate ambulance level of care and required origin and destination modifiers.

Ambulance base-rate and mileage rules

Apply all of the following ambulance base-rate and mileage rules:

ALL of the following

Bill the ambulance base rate per trip at the appropriate level of care.
Bill mileage separately when otherwise reimbursable.
Do not separately bill equipment, supplies, oxygen, intravenous drugs, or ambulance personnel services included in the base rate.

Nonreimbursable services

The following services and circumstances are nonreimbursable under this policy:

ANY of the following

Non-emergency medical transport (NEMT).
Mileage when the transport service has been denied or is not covered.
A member who is not available (no-show); additional rates for night, weekend, or holiday calls; mileage in transit to pick up or drop off the member (unloaded mileage); mileage for additional passengers; or mileage for an extra attendant for additional passengers.
Transport for a member's or caregiver's convenience; transport available free of charge; transportation vendor or supplier lodging or meals; or vehicle maintenance or gas.
Ambulance transports other than for medical care; transport where another means of transportation could be used without endangering the member's health; or transport from or to a home and a facility other than a hospital, skilled nursing facility, dialysis facility, or nursing home.

Transportation Modifiers

Origin and destination modifiersModifier

D	Diagnostic or therapeutic site other than a physician's office or hospital; origin and destination modifier
E	Residential, domiciliary, or custodial facility; origin and destination modifier
G	Hospital-based dialysis facility, hospital, or hospital-associated facility; origin and destination modifier
H	Hospital, inpatient or outpatient; origin and destination modifier
I	Site of transfer between two types of ambulance; origin and destination modifier
J	Nonhospital-based dialysis facility; origin and destination modifier
N	Skilled nursing facility, including swing bed; origin and destination modifier
P	Physician's office, including HMO nonhospital facility or clinic; origin and destination modifier
R	Private residence; origin and destination modifier
S	Scene of accident or acute event; origin and destination modifier

1–10 of 11

1/2

Additional ambulance transportation modifiersModifier

GM	Multiple members on one trip; additional to origin and destination modifiers
QL	Member died after the ambulance was called; origin and destination modifiers are not required with this modifier
QM	Provider arranged for transportation services; additional to origin and destination modifiers
QN	Provider furnished the transportation services; additional to origin and destination modifiers
TK	Multiple carry trips; additional to origin and destination modifiers
TQ	Life-support transport by a volunteer ambulance provider; additional to origin and destination modifiers

Billing and Documentation Requirements

Documentation Required

Use compliant codes and supporting documentation

Submit claims using industry-standard, compliant CPT, HCPCS, and/or revenue codes. The codes must accurately denote the services performed and be fully supported in the medical record and/or office notes.

Billing Rule

Report origin and destination modifiers

Bill transportation claims with the applicable origin and destination modifiers. Claims submitted without these modifiers may be denied.

Billing Rule

Transportation Terms

Advanced Life Support (ALS)

Service typeInvasive services.

PersonnelProvided by emergency medical technicians trained at the intermediate or paramedic level.

RequirementsProvided in conjunction with applicable state laws.

Basic Life Support (BLS)

Service typeNoninvasive services.

PersonnelProvided by basic emergency medical technicians.

RequirementsProvided in conjunction with applicable state laws.

Policy Summary

PayerHealthy Blue Louisiana

PolicyTransportation Services: Ambulance and Non-Emergent Transport

Policy CodePolicy N/A

Change TypeMaterial update

Effective Date05/22/2024

Next Review DateN/A

Key ActionBill transportation claims with the applicable origin and destination modifiers; claims without these modifiers may be denied.

SourceLink

On This Page

Separate reimbursement for services or items included in the base ambulance rate; a higher level of care when a lower level is more appropriate; both basic and advanced life support when ALS services are provided; or EMT services billed in addition to ALS or BLS base rates.

Services provided on the ambulance by hospital staff; additional ground or air ambulance providers that respond but do not transport the member; transport of persons other than the member and a medically required attendant who do not require medical attention; or transport for a member pronounced dead before the ground or air ambulance was contacted.

Mileage beyond the nearest appropriate facility (excessive mileage).

Wait-time fees and outreach fees.

Use the appropriate level of care and destination

Bill the ambulance base rate per trip according to the appropriate level of care provided, and transport the member to the nearest facility equipped to provide the required treatment. Do not bill a higher level of care when a lower level is more appropriate or seek reimbursement for mileage beyond the nearest appropriate facility.

Prior Authorization

Meet authorization and medical-necessity requirements

Confirm that the service meets applicable authorization and medical-necessity requirements in addition to the member’s benefit coverage. Coverage under the benefit plan does not by itself establish reimbursement eligibility.

Denial Risk

Avoid denial and payment recovery

Follow proper coding, billing, submission, authorization, and reimbursement-policy requirements. Failure to do so may result in claim rejection or denial, payment recovery or recoupment, or adjustment of reimbursement.

Air ambulance

VehicleAn equipped and staffed aircraft; air ambulances may be rotary-wing (helicopter) or fixed-wing (commercial or private aircraft).

DestinationTransports the member to the nearest appropriate facility.

Transport requirementUsed when ground ambulance transport could not otherwise be accomplished without endangering the member’s health.

Ambulance transportation

Transport typeMedically necessary transport of a member by medically skilled personnel.

DestinationThe nearest appropriate facility equipped to provide care for the member’s injury or illness.

Service categoriesServices are delineated as Basic Life Support (BLS) or Advanced Life Support (ALS), and as emergency or non-emergency.

Emergency ambulance transportation

Service typeAn urgent service for the sudden, unexpected onset of an acute illness or injury.

Care requiredRequires immediate medical or surgical care, obtained immediately after onset or as soon thereafter as practical.

Risk of delayWithout immediate treatment, the condition could result in death or permanent impairment to the member’s health.

Ground ambulance

VehicleAn equipped and staffed land or water vehicle.

Transport positionDesigned to transport a member in the supine position.

Vehicle requirementThe vehicle must be equipped and staffed for the member’s transport.

Nonemergency ambulance transportation

SchedulingMay be a scheduled or unscheduled service.

Personnel requirementThe member requires attention by EMT-trained personnel while in transit.

Service distinctionThe defining characteristic is the need for EMT-trained attention during transport rather than the transport schedule.

Non-Emergency Medical Transport (NEMT)

PersonnelTransport is provided by non-medically skilled personnel, such as laypersons.

PurposeThe member is transported to receive covered services.

ExamplesExamples include an ambulette or medi-van, wheelchair van, invalid coach, taxicab, minibus, or public transportation such as a bus or subway.