Non-Emergency Ambulance Transportation (NEMT)
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Defines medical necessity, documentation, and prior authorization requirements for non-emergency ground ambulance transportation for Longevity Health Plan of Colorado beneficiaries, based on Medicare Benefit Policy Manual Chapter 10.
No material clinical or coverage changes in this revision.
Medical Necessity and Coverage Rules
Medical Necessity Criteria
Covered when ALL of the following are met
Based on Medicare Benefits Policy Manual; availability of alternative services does not affect medical necessity determination.
Presence of these items defines bed-confinement but does not alone prove medical necessity.
Physician or non-physician certification statement required; certification alone does not prove medical necessity.
This policy addresses non-emergency ground ambulance (NEMT) services only. Air ambulance services are not defined within this document and are subject to a separate prior authorization and medical necessity review as described by Medicare Policy Manual Chapter 10.
Documentation supplied as blanket statements, addendums, attestations, or letters of medical necessity alone are insufficient to support coverage. Such items must be accompanied by the original clinical documentation from the beneficiary's medical record to substantiate the request.
Ambulance transport is not medically necessary when the member can be transported by stretcher, wheelchair, or any other non-ambulance ground transportation without endangering the member’s health. Medical necessity is determined by the member’s condition and is not dependent on whether alternative transportation is actually available.
Prior Authorization, Documentation, and Authorization Duration
Prior authorization required for NEMT ambulance services
Prior authorization is required for Non‑Emergency Medical Transportation (NEMT) ambulance services; PA requests must include the documentation elements outlined in the policy to support medical necessity, including the required clinical evidence and a physician (or non‑physician) certification when applicable.
- PA required before NEMT ambulance services will be covered.
- Include all clinical documentation elements described in policy to support medical necessity.
PA duration for recurrent/scheduled NEMT
For recurrent, repetitive, or scheduled NEMT ambulance services, prior authorization may be issued for the duration of treatment or for up to 3 months at a time; approved units are based on the frequency of services (example: dialysis 3×/week → 72 one‑way trips for 3 months).
- Authorization covers duration of treatment or maximum 3 months, whichever comes first.
- Units approved during the PA window are based on service frequency (example provided).
Follow PA and documentation requirements
Providers must follow all prior authorization and documentation requirements in the policy when requesting coverage for NEMT ambulance services; include the clinical assessment data and certification described in the policy to avoid denial.
- Submit clinical assessment data with objective findings.
- Include physician or non‑physician certification as required.
Complete and timely PA submissions
Ensure prior authorization requests are complete and timely—include the specific clinical findings, certification, and supporting medical record documentation referenced in the policy to support medical necessity determinations.
- Incomplete or late PA submissions risk denial; attach original medical record documentation rather than standalone attestation.
Include signed physician (or non‑physician) certification
Prior authorization requests must include clinical documentation supporting medical necessity, including a signed physician certification statement (or a non‑physician certification if a physician signature is unavailable).
- Physician certification must be signed and dated and certifies that the policy's medical necessity provisions are met.
- If the attending physician signature cannot be obtained, a non‑physician certification statement must be submitted per policy.
Required clinical assessment elements for PA
Provide objective clinical assessment data: history of condition and/or reason the beneficiary is unable to ambulate or get out of bed; muscle strength scale assessment including trunk strength; physical mobility assessment with transfer ability and activities of daily living (ADLs); and any other applicable clinical data.
- History/reason why beneficiary cannot ambulate or get out of bed
- Muscle strength scale assessment, including trunk strength
- Physical mobility assessment with transfer ability and ADLs
- Any and all applicable clinical data supporting the beneficiary's condition
Authorization period and example units for recurrent NEMT
Recurrent NEMT prior authorizations may cover the duration of treatment or for up to 3 months at a time; approved units during the authorization window will be based on service frequency (example: dialysis three times per week results in authorization for 72 one‑way trips over 3 months).
- Maximum PA coverage period for recurrent/scheduled NEMT: up to 3 months.
- Example units: dialysis 3×/week → 72 one‑way trips for 3 months.
Denial risk: alternative transport available
Ambulance services are not payable when another method of transportation could be used without endangering the member's health; availability of alternative services does not affect this determination.
- If member can safely be transported via stretcher, wheelchair, or other non‑ambulance ground transport, ambulance transport is not medically necessary.
- Medical necessity is not dependent on whether alternative services are actually available.
Insufficient documentation risk—LMNs/attestations not enough
Blanket statements, addendums, attestations, and letters of medical necessity will not stand alone; original medical record documentation must be provided to support the PA request and medical necessity determination.
- LMNs, attestations, or addenda without the underlying medical record are insufficient.
- Include original documentation from the beneficiary's medical record as support.
Key Terms and Abbreviations
Policy Background and Guiding References
This policy follows the Medicare Benefit Policy Manual Chapter 10 guidance that ambulance transport is medically necessary only when use of any other method of transportation is contraindicated. If another transportation method could be used without endangering the individual’s health, ambulance services are not payable.
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