CurrentHumanaPolicy CP2023009

Ambulance Services

Humana Medicare Advantage payment policy governing billing, reimbursement, and documentation requirements for ground and air ambulance transportation for Humana MA members; applies to licensed ambulance providers billing Humana for covered ambulance services.

Policy Summary

PayerHumana

PolicyAmbulance Services

Policy CodePolicy CP2023009

Change TypeNo material change

Effective DateSep 1, 2023

Next Review DateN/A

Key ActionWhen Humana authorizes admission to a facility in advance, Humana reimburses mileage to that facility; claim payments remain subject to medical necessity and plan authorization requirements.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

A0425,A0435,A0436,A0888HCPCS mileage codes referenced

75%/50%Two patients transport

60%/proratedThree patients transport

ZIP POPBilling requirement

0.1 miMileage precision

Coverage and Billing Criteria

Covered when services meet Medicare medical necessity and Humana MA plan rules. Reimbursement and billing follow Original Medicare guidelines unless modified by this policy.

ALL of the following

Transportation is medically necessary according to Medicare guidelines and plan requirements (medical necessity, reasonableness, applicable referral/authorization).
Humana MA follows Original Medicare guidelines for ambulance coverage.
Provider bills only covered transportation and mileage charges; reimbursement includes all items/services provided during transport (no separate payment for oxygen, drugs, extra attendants, supplies, ECG/EKG, night differential).
Ambulance transportation for a member registered as an inpatient at a hospital or SNF must be included in the facility’s consolidated inpatient claim; transportation charges considered within the inpatient adjudication.

Policy Summary

PayerHumana

PolicyAmbulance Services

Policy CodePolicy CP2023009

Change TypeNo material change

Effective DateSep 1, 2023

Next Review DateN/A

SourceLink

On This 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.

Ambulance Coding and Reimbursement

Ambulance mileage HCPCSHCPCS

A0425	Ground mileage, per statute mile
A0435	Fixed wing air mileage, per statute mile
A0436	Rotary wing air mileage, per statute mile
A0888	Non-covered ambulance mileage, per mile (e.g., for miles beyond closest appropriate facility)

Required modifiersModifier

GM	Modifier for multiple patients on one ambulance trip
QL	Modifier when patient pronounced dead after ambulance called

inv-04: Mileage reimbursement to nearest facility — reimbursed only to nearest appropriate facility unless admission authorized in advance

Reimbursement ruleReimbursed only to the nearest appropriate facility; exception: when Humana authorizes admission to a facility in advance, Humana reimburses mileage to that authorized facility.

Billing codes for coverable mileageProviders should bill coverable mileage with HCPCS A0425, A0435 or A0436.

Non‑covered mileage code handlingIf mileage beyond the closest facility is billed with HCPCS A0888, Humana will not reimburse and will deny it to provider liability; bill A0888 when facility did not obtain prior authorization for the related admission.

Multiple‑patient adjustment impactMultiple‑patient transports affect reimbursement (see modifier GM): adjustments apply to transport and mileage when more than one patient is on board.

Provider Requirements and Billing Actions

Prior Authorization

Prior authorization / admission-related mileage reimbursement

When Humana authorizes admission to a facility in advance (regardless of whether prior authorization is otherwise required), Humana will reimburse mileage for ambulance transportation to that facility; claim payments remain subject to medical necessity and plan authorization requirements. If mileage is billed with HCPCS code A0888 for transport beyond the closest facility, Humana will not reimburse that charge and will deny it to provider liability.

Bill coverable mileage with HCPCS A0425, A0435 or A0436 when applicable.
Use HCPCS A0888 only when facility did not obtain prior authorization for an admission and mileage beyond the closest facility is billed; A0888 will not be reimbursed and will be denied to provider liability.
Claims remain subject to medical necessity, reasonableness, and any applicable referral or authorization requirements.

Billing Rule

Out-of-network payment acceptance (42 CFR 422.214)

Out-of-network providers must accept, as payment in full, the amount they could collect if the patient were enrolled in Original Medicare per 42 CFR 422.214; the provider may collect the member's required cost-sharing and seek the remainder from the MA plan.

Provider may collect member cost-sharing required under the MA plan.
Provider may bill the MA plan for the remainder of the allowed amount.

Definitions

inv-07: Ambulance — definition of 'Ambulance'

DefinitionAn ambulance is a professionally operated vehicle, provided by a licensed ambulance service, equipped for the transportation of a sick or injured person to or from the nearest medical facility qualified to treat the person's sickness or bodily injury.

Provider/vehicle requirementOperated by a licensed ambulance service and equipped for patient transportation.

Intended useTransport of sick or injured persons to or from appropriate medical facilities; subject to Humana billing and reimbursement policy.

inv-08: Base maximum amount payable under the member's plan — definition/explanation

Base maximum amount payable — definitionThe maximum amount of reimbursement for a covered expense determined by the member's plan; may be the maximum allowable fee, the applicable Medicare fee schedule rate, or an amount from another payment model; actual reimbursement may be less due to adjustments.

Use in multiple‑patient adjustmentsHumana applies the base maximum amount payable under the member's plan when calculating reduced payment percentages for multiple‑patient transports (e.g., 75% or 60% of transportation rates).

Relation to provider contracted rateHumana compares provider's contracted rate or the plan's base maximum amount payable when determining allowed reimbursement for transportation and mileage.

inv-09: Key ambulance modifiers — definitions for modifiers GM and QL

Modifier GMDenotes multiple patients on one ambulance trip; Humana adjusts reimbursement when GM is reported (e.g., two patients: 75% of transport rate and 50% of mileage; three patients: 60% of transport rate and prorated mileage).

Modifier QLReport when patient is pronounced dead after ambulance is called; indicates mileage is not covered for that transport circumstance.

Billing requirementOrigin and destination modifiers (listed in definitions) must be billed with transportation and mileage charges along with GM or QL as applicable.