CurrentHumanaPolicy CP2023009

Ambulance Services — Medicare Advantage Payment Policy

Billing requirements and reimbursement policies for medically necessary ground and air ambulance transportation for Humana Medicare Advantage products and the providers who serve Humana members.

Policy Summary

PayerHumana

PolicyAmbulance Services — Medicare Advantage Payment Policy

Policy CodePolicy CP2023009

Change TypeNo material changes

Effective Date09/2023

Next Review Date

Key ActionWhen Humana authorizes admission to a facility in advance, bill mileage to that facility (use A0425/A0435/A0436 for reimbursable mileage; A0888 denotes non‑covered mileage).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Medicare Advantageproduct applicability

CP2023009policy identifier

A0425,A0435,A0436reimbursable mileage codes

A0888non-covered code

GM, QLrequired modifiers

Ambulance Coverage Criteria and Billing Rules

Policy Summary

PayerHumana

PolicyAmbulance Services — Medicare Advantage Payment Policy

Policy CodePolicy CP2023009

Change TypeNo material changes

Effective Date09/2023

Next Review Date

Key ActionWhen Humana authorizes admission to a facility in advance, bill mileage to that facility (use A0425/A0435/A0436 for reimbursable mileage; A0888 denotes non‑covered mileage).

SourceLink

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Ambulance coverage criteria and billing rules

Covered when ALL of the following criteria and billing rules are met:

ALL of the following

Transport must be medically necessary and reasonable and subject to plan medical necessity, reasonableness, and any applicable referral or authorization requirements.
Humana MA follows Original Medicare guidelines for medical necessity.

ALL of the following

Ambulance transportation provided while member is registered as an inpatient must be included in the facility's consolidated inpatient claim; charges for transportation of an inpatient will only be considered within the adjudication of the inpatient stay.

ALL of the following

Mileage reimbursement is generally limited to distance to the nearest appropriate facility.
Exception - authorized admission: When Humana authorizes admission to a facility in advance (regardless of whether prior authorization is otherwise required), Humana reimburses mileage to that facility.

ALL of the following

Providers should bill coverable mileage with HCPCS A0425, A0435 or A0436.
If a provider bills mileage with HCPCS A0888 for miles beyond the closest appropriate facility, Humana will not reimburse that charge and will deny it to provider liability (use A0888 only when facility did not obtain prior authorization for admission beyond closest facility).

ALL of the following

Report modifier GM when multiple patients are simultaneously transported in the same ambulance to the same destination.
Reimbursement adjustments: If two patients are transported: allow 75% of transportation rate and 50% of mileage; if three patients: allow 60% of transportation rate and prorated mileage percentage based on number of patients on board.

ALL of the following

If patient is pronounced dead after dispatch but before being loaded, report modifier QL with the transportation charge instead of origin/destination modifiers; mileage is not covered. If mileage is reported with QL, it will not be reimbursed.

ALL of the following

Providers must bill appropriate ambulance origin and destination modifiers with both transportation and mileage charges; origin/destination modifiers use first letter for place of origin and second for destination.
Providers must bill the ZIP code of the point of pickup (POP).

ALL of the following

For transports under 100 miles, mileage may be reported in fractional units to the nearest tenth of a mile.

ALL of the following

When more than one hospital-to-hospital ambulance service is provided on the same day, submit each segment as a separate claim line with a unit of 1.

ALL of the following

Humana only reimburses for covered transportation and mileage charges; the amount allowed for transportation includes reimbursement for other items/services provided during transport (e.g., oxygen, drugs, extra attendants, supplies, ECG) and Humana does not separately reimburse for those items.

ALL of the following

Under 42 CFR 422.214 an out-of-network provider must accept as payment in full the amount the provider could collect under Original Medicare; the provider may collect member cost-sharing and collect the remainder from the MA plan.

ALL of the following

Some Humana MA plans may offer supplemental transportation benefits beyond Original Medicare; providers and members should verify coverage with Humana.

Ambulance Coding and Mileage Reporting

Ambulance mileage HCPCS (covered)HCPCSCovered

A0425	Ground mileage, per statute mile
A0435	Fixed wing air mileage, per statute mile
A0436	Rotary wing air mileage, per statute mile

Ambulance mileage HCPCS (not covered)HCPCSNot Covered

A0888

Non-covered ambulance mileage, per mile (e.g., for miles beyond closest appropriate facility)

Mileage reporting precision

Mileage reporting precisionFor transports under 100 miles, ambulance mileage may be reported in fractional units to the nearest tenth of a mile.

Applies toAll ambulance transports under 100 miles billed to Humana Medicare Advantage plans.

Billing requirementReport mileage using tenths of a mile (e.g., 12.3 miles) when distance is less than 100 miles.

Hospital-to-hospital same-day claims

Same-day hospital-to-hospital segmentsWhen more than one hospital-to-hospital ambulance service occurs on the same day, submit each segment as a separate claim line with a unit of 1.

Unit of serviceEach segment must be billed with unit = 1 (do not aggregate multiple segments on one line).

Claims submissionEnsure separate line-level detail for each hospital-to-hospital transport segment on the same date of service.

Authorization, Documentation, and Billing Actions for Providers

Prior Authorization

Authorization and mileage when admission authorized

When Humana authorizes admission to a facility in advance (regardless of whether prior authorization is required), the provider should bill all coverable ambulance mileage to that authorized facility using HCPCS code A0425, A0435, or A0436. Do not bill mileage to the authorized facility with HCPCS code A0888 — Humana will not reimburse A0888 and will deny it to provider liability. If the facility did not obtain prior authorization from Humana for the related admission, bill mileage for transportation beyond the closest facility with HCPCS code A0888; Humana will not reimburse that charge but will deny it to provider liability. When multiple patients are transported simultaneously to the same destination (modifier GM), reimbursement for transportation and mileage is adjusted: for two patients Humana allows 75% of the contracted rate (or base maximum) for transportation and 50% for mileage; for three patients Humana allows 60% of the contracted rate (or base maximum) for transportation and a prorated percent for mileage based on number of patients on board.

Bill coverable mileage to an authorized facility with HCPCS A0425, A0435, or A0436.
Do not bill authorized-facility mileage with A0888 — A0888 will be denied to provider liability.
If facility admission was not authorized by Humana, bill mileage beyond the closest facility with A0888; Humana will not reimburse and will deny to provider liability.
When modifier GM indicates multiple patients transported to same destination: two patients = 75% transportation / 50% mileage; three patients = 60% transportation / prorated mileage.

Key Definitions and Modifiers

Modifier GM

Modifier GM definitionModifier GM indicates multiple patients on one ambulance trip.

Reimbursement effect (brief)Humana adjusts reimbursement when multiple patients are transported (see policy for percentage adjustments).

UsageApply Modifier GM on claims when two or more patients are transported on the same trip to reflect multiple-patient pricing.

Modifier QL

Modifier QL definitionModifier QL indicates the patient was pronounced dead after the ambulance was called/ dispatched.

Billing effectUse modifier QL with the transport charge; mileage is not covered when QL is reported.

When to useReport QL when patient pronouncement occurs after ambulance dispatch to document non-transport reimbursement status.

Base maximum amount payable under the member's plan

DefinitionThe base maximum amount payable under the member's plan is the maximum reimbursement for a covered expense as determined by the member's plan (may be the maximum allowable fee, Medicare fee schedule rate, or another payment model).

Plan variabilityActual plan reimbursement may be less than the base maximum amount because of applicable adjustments.

Role in adjudicationThis base maximum defines the ceiling used by Humana when determining payment for covered ambulance services under the member's plan.

Ambulance

Ambulance definitionA professionally operated vehicle, provided by a licensed ambulance service, equipped for transportation of a sick or injured person to or from the nearest medical facility qualified to treat the person.

Provider requirementsVehicle must be professionally operated and provided by a licensed ambulance service.

PurposeEquipped for transporting sick or injured persons to/from the nearest qualified medical facility for treatment.