CurrentHighmark Blue Cross Blue Shield WnyPolicy N/A

Transportation Services: Ambulance and Nonemergent Transport

Defines Highmark BCBS WNY reimbursement rules for ambulance and nonemergency medical transportation (NEMT) for applicable member programs, including what is reimbursable, nonreimbursable, billing modifiers, and vendor responsibilities. Affects providers submitting claims for ambulance and NEMT services under Highmark BCBS WNY-managed programs referenced in the policy.

Policy Summary

PayerHighmark Blue Cross Blue Shield Wny

PolicyTransportation Services: Ambulance and Nonemergent Transport

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date01/01/18

Next Review DateN/A

Key ActionEnsure services meet authorization and medical necessity guidelines appropriate to the procedure, diagnosis, and member's state of residence before submitting claims.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

01/01/18Effective date

07/13/18Last approval

State vendorNEMT model

Modifiers requiredBilling enforcement

6Document page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage and Reimbursement Rules

Coverage criteria and rules

Reimbursement is allowed when transport is to/from covered services or other contract-mandated services and meets medical necessity, authorization, and billing requirements. Specific included, separately reimbursable, and excluded items are listed below.

Applies to transports for covered services and contract-mandated services; providers should also review state guidelines for coverage requirements.

Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis and member's state of residence; reimbursement is allowed for transport to and from covered services or other contract-mandated services unless contracts require otherwise.

Vendor model: Nonemergency medical transport (NEMT) and emergency services for specified programs are provided through state vendor(s) (not Highmark BCBS). For NEMT, reimbursement is based on claims or vendor invoices showing base trip rate, mileage, and parking/tolls.

Reimbursed items: Ambulance reimbursement is based on the base trip rate (defined by origin/destination modifiers) according to the medically necessary level of care; reimbursement also follows the fee schedule or contracted rate for items separately reimbursable from the base rate.

ALL of the following

Disposable/first-aid supplies
Reusable devices/equipment
Oxygen
Intravenous drugs
Ambulance personnel services

Separately reimbursable

Mileage
Additional, appropriately licensed medical personnel as medically necessary for the member's health status
Unusual waiting time
Disposable/first-aid supplies in greater than normal use

Inpatient transfer rule: If ambulance transport is medically necessary for inpatient-to-inpatient transfer between hospital-based facilities, reimbursement is included in the inpatient stay and is not separately reimbursed; exception: newborn transport from birth hospital to a regional perinatal care center is separately reimbursed.

Billing requirements: Claims must be billed with origin/destination modifiers that define the trip; claims submitted without origin/destination modifiers will be denied.

Nonreimbursable scenarios (applies to ambulance and medical transport unless noted)

A member who is unavailable (no-show)
Additional rates for night, weekend and/or holiday calls
Mileage in transit to pick up or drop off the member (unloaded mileage)
Mileage for additional passengers or for extra attendant for additional passengers
Mileage when the transport service has been denied or is not covered
Transport for a member's or caregiver's convenience

Operational note: Reimbursement for medical transport (NEMT) is based on vendor invoices or contracted transportation vendor claims showing the nonemergency medical transport base rate per trip (defined by origin/destination modifiers), mileage, and parking/toll fees.

Coding, Modifiers, and Billing Rules

Accepted Coding Systemsmixed

CPT	Current Procedural Terminology codes for professional services
HCPCS	Healthcare Common Procedure Coding System for supplies and non-physician services
Revenue	Revenue codes for facility billing where applicable

Origin / Destination Modifiers (required)Modifier

D	Diagnostic or therapeutic site/free standing facility other than P or H
E	Residential, domiciliary, custodial facility
G	Hospital-based dialysis facility (hospital or hospital-associated)
H	Hospital (inpatient or outpatient)
I	Site of transfer between types of ambulance
J	Nonhospital-based dialysis
N	Skilled nursing facility, including swing bed
P	Physician's office, including HMO nonhospital facility, clinic, etc.
R	Private residence
S	Scene of accident or acute event

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Inpatient transfer billing rule — ambulance medically necessary for inpatient-to-inpatient transfer is included in inpatient stay and not separately reimbursed.

Inpatient transfer billing ruleIf ambulance transport is medically necessary for inpatient-to-inpatient transfer between hospital-based facilities, reimbursement is included in the inpatient stay and not separately reimbursed.

Authorization, Documentation, and Vendor Responsibilities

Note

Authorization and medical necessity — document and code to support transport

Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis as well as to the member's state of residence; reimbursement is allowed for transport to and from covered services or other services mandated by contract unless provider, state, federal or CMS contracts or requirements indicate otherwise. Providers must follow proper billing and submission guidelines and use industry-standard CPT, HCPCS and/or revenue codes supported by documentation; failure to follow appropriate coding/billing or reimbursement policies may result in claim rejection or denial, recovery/recoupment of payment, or adjusted reimbursement.

Obtain any required prior authorization and document medical necessity consistent with procedure, diagnosis, and member's state of residence.
Use industry-standard CPT, HCPCS and/or revenue codes on claim submissions and ensure documentation in the medical record supports billed services.
Be aware that state, federal, provider, or CMS contracts may supersede this policy and alter authorization or coverage requirements.

Key Definitions

Basic Life Support (BLS) — inv-06

DefinitionBasic Life Support (BLS) consists of noninvasive services provided by personnel trained as EMTs (basic) in conjunction with state laws.

Level of careBLS is an initial level of ambulance care and is distinguished from ALS by noninvasive interventions.

Provider qualificationServices are provided by personnel trained as EMTs (basic) according to applicable state laws.

Advanced Life Support (ALS) — inv-07

DefinitionAdvanced Life Support (ALS) consists of invasive services provided by personnel trained as EMTs (intermediate or paramedic) in conjunction with state laws.

Level of careALS includes invasive interventions beyond BLS and is used when medically necessary based on member condition.

Policy Summary

PayerHighmark Blue Cross Blue Shield Wny

PolicyTransportation Services: Ambulance and Nonemergent Transport

Policy CodePolicy N/A

Change TypeNo material changes

Effective Date01/01/18

Next Review DateN/A

Key ActionEnsure services meet authorization and medical necessity guidelines appropriate to the procedure, diagnosis, and member's state of residence before submitting claims.

SourceLink

On This Page

Transport available at no extra cost

Ambulance-only exclusions: For ambulance services only: for reasons other than medical care; when another means of transportation could be used without endangering the member's health; separate reimbursement for services/items included in the base ambulance rate; for a higher level of care when a lower level is more appropriate; for BLS and ALS when ALS services are provided; for services provided by the EMT in addition to ALS or BLS base rates; for services provided on the ambulance by hospital staff; additional ground or air ambulance providers that respond but do not transport the member; transport from the member's home to a facility other than a hospital, skilled nursing facility, dialysis facility or nursing home; transport from a facility other than a hospital, skilled nursing facility, dialysis facility or nursing home to the member's home; transport of persons other than the member and a medically required attendant who do not require medical attention; transport for a member pronounced dead before the contact of ground or air ambulance; mileage beyond the nearest appropriate facility (excessive mileage)

Medical-transport-only exclusions: For medical transport services only: transportation vendor or supplier lodging or meals; vehicle maintenance or gas

Provider qualificationServices are provided by personnel trained as EMTs (intermediate or paramedic) according to applicable state laws.

Ground ambulance — inv-08

DefinitionGround ambulance: an equipped and staffed land or water vehicle designed to transport a member in the supine position.

IncludesLand ambulances and water vehicles equipped and staffed for supine transport.

Use caseUsed to transport members to the nearest appropriate facility when ground transport is appropriate and safe.

Air ambulance — inv-09

DefinitionAir ambulance: an equipped and staffed aircraft (rotary- or fixed-wing) necessary to rapidly transport a member to the nearest appropriate facility when ground transport would endanger the member's health or cannot accomplish the transport.

TypesIncludes rotary‑wing (helicopter) and fixed‑wing (commercial or private aircraft).

IndicationUsed when rapid transport is required and ground ambulance access would endanger the member's health or is not feasible.

Nonemergency medical transport (NEMT) — inv-10

DefinitionNonemergency medical transport (NEMT) entails the transport of a member by nonmedically skilled personnel to receive covered services.

ExamplesAmbulette/medi‑van, wheelchair van, invalid coach, taxicab, minibus, and public transportation (e.g., bus, subway).

Vendor model and reimbursementNEMT services are provided through a state vendor; reimbursement is based on base trip rate defined by origin/destination modifiers, mileage, and parking/tolls, and is billed via contracted transportation vendors or suppliers.

Transportation Services: Ambulance and Nonemergent Transport

Coverage and Reimbursement Rules

Coding, Modifiers, and Billing Rules

Authorization, Documentation, and Vendor Responsibilities

Key Definitions

Related Policies and References