ModifiedMass General Brigham Health PlanPolicy 037

Non-Emergency Transportation Medical Necessity Criteria

Defines Mass General Brigham Health Plan medical necessity, prior-authorization, coverage, exclusions, documentation, and payer-specific variations for non-emergency ground ambulance, chair car, interfacility air/sea ambulance, and interfacility ground transportation for plan members.

Policy Summary

PayerMass General Brigham Health Plan

PolicyNon-Emergency Transportation Medical Necessity Criteria

Policy CodePolicy 037

Change TypeAd hoc and annual updates (2023–2026)

Effective Date

Next Review Date

Key ActionObtain required prior authorization and submit a completed Physician Certification Statement (PCS) for all non-emergency transportation requests per the plan-specific prior authorization table; use the alternate Ground Transportation Request form when applicable.

SourceLink

POLICY UPDATE CHANGES

January 2026: Ad hoc update: Updated prior authorization table and added variation for OneCare and SCO members. Clarified coverage of chair car services for OneCare and SCO members. Added hyperlink to MassHealth transportation services regulations.

September 2024: Annual update: Clarified language around transport methods. Clarified Medicare variation language. Added MassHealth variation.

September 2025: Annual update. Updated code disclaimer.

September 2023: Annual update: Medicare Advantage added to prior authorization table; Medicare Variation language added; references updated; clarified interfacility transfer definition and coverage from facility to residence in certain circumstances.

4Primary transport modalities covered (ground, chair car, air, sea)

13Explicit exclusions listed

Required documentation forms (PCS)

multi-payerPayer variations included (Medicare, MassHealth, OneCare, SCO)

Coverage Summary

Key policy-level facts

Primary transport modalities covered4

Explicit exclusions listed13

Required documentation forms1

Payer variations includedmulti-payer

Policy number / Status / Last reviewPolicy 037 / MODIFIED / Last review 2026-01

Medical Necessity Criteria

Non-Emergency Medically Necessary Ground Ambulance Transportation

Covered when ALL of the following are met and when authorized by Mass General Brigham Health Plan:

ALL of the following

ALL of the following
- This method of transportation is the least intensive, medically necessary method.
- The member's condition does not allow them to access a less restricted method of transportation (e.g., personal vehicle, taxi, public transportation, walking) when normally accessing the community.
- Member meets at least ONE of the following additional criteria
  - Member is bed confined (unable to sit in a chair or a wheelchair) including post cardiac catheterization at an outside facility.
  - Member is confined to a wheelchair and resides in a home that prevents access via less restrictive transportation.

Non-Emergency Medically Necessary Chair Car Transportation

Covered when ALL of the following are met and when authorized by Mass General Brigham Health Plan (Commercial, MGB ACO, OneCare, and SCO members only; Not covered for Medicare Advantage unless also enrolled in MassHealth):

ALL of the following

The member's medical condition prevents safe transportation by any other means and this method of transportation is the least intensive, medically necessary method.
Member meets at least ONE of
- Member's condition does not allow them to access a less restricted method of transportation (e.g., personal vehicle, taxi, public transportation, walking) when normally accessing the community.
- Member is unable to safely transfer from a wheelchair to a vehicle with or without assistance.

Non-Emergency Medically Necessary Interfacility Air/Sea Ambulance Transportation

Covered with authorization when transporting to a covered and authorized medically appropriate facility and when ALL of the following apply:

ALL of the following

Member's medical condition requires medical attention during transport.
AND at least ONE of
- Use of ground transportation is contraindicated or inappropriate to ensure the member's safe transfer.
- A ground ambulance cannot be used to access the member (e.g., pick-up point not accessible by land vehicle).
Also covered when
- An ill or injured member who received urgent or emergency care outside the service area is medically stable for transport back to the plan service area but requires medical attention during transport to ensure a safe return (plan determines medical necessity and appropriateness).

Non-Emergency Medically Necessary Interfacility Ground Transportation

Covered to/from acute medical hospital, acute rehabilitation hospital, skilled nursing facility, and long-term acute care facility when plan has authorized the admission and the following are met (no authorization required for interfacility when plan authorized admission):

ALL of the following

Services must be related to at least ONE of
- Related to the member's current reason for care.
- Pertinent to the advancement of the member's care.
- For diagnostic services that if delayed until after discharge could cause harm.
The least intensive type of transportation that meets the member's medical condition must be used independent of availability.

Provider Actions & Requirements

Prior Authorization

Prior authorization required for non-emergency transportation

Authorization is required for non-emergency medically necessary transportation (ground ambulance, chair car, and air/sea ambulance) per the plan-specific prior authorization table. Some services and situations are exempt — see the policy's 'No Prior Authorization is required' list for specific exemptions.

See the plan-specific prior authorization table in the policy for which products require authorization
See the 'No Prior Authorization is required' list for exemptions (e.g., emergency ambulance, emergency air ambulance, interfacility transfers when specified)

Documentation Required

Physician Certification Statement (PCS) required

A completed Physician Certification Statement (PCS) for Non-Emergency Ambulance Services form is required to support medical necessity determinations for all non-emergency ambulance services (ground, sea, air). All documentation must be legible and in English.

Coding

Informational CPT/HCPCS codes listed (inclusion does not imply coverage)HCPCS

A0130
A0140	Nonemergency transportation and air travel (private or commercial) intra- or interstate.
A0426	Ambulance service, advanced life support, nonemergency transport, level 1 (ALS 1).
A0428	Ambulance service, basic life support, nonemergency transport (BLS).
A0434	Specialty care transport (SCT).
A0380	BLS mileage (per mile).
A0425	Ground mileage, per statute mile.
A0430	Ambulance service, conventional air services transport, one way (fixed wing).
A0431	Ambulance service, conventional air services, transport, one way (rotary wing).
A0435	Fixed wing air mileage per statute mile.

1–10 of 13

1/2

The listed CPT/HCPCS codes are provided for informational purposes only; inclusion does not imply coverage. The policy code list includes ambulance, mileage, and nonemergency transport codes (e.g., A0130, A0140, A0426, A0428, A0434, A0380, A0425, A0430, A0431, A0435, A0436, S9960, S9961). The policy notes an updated code disclaimer in the September 2025 annual update.

Background & Definitions

This policy defines Mass General Brigham Health Plan coverage criteria for non-emergency transportation services — including non-emergency ground ambulance, chair car (wheelchair van), interfacility air/sea ambulance, and interfacility ground transportation — and explains payer-specific variations. It outlines prior authorization requirements and exclusions, and describes interplay with MassHealth (MassHealth directly covers non-emergent transportation in-state and up to 50 miles from the Massachusetts border and some services must be submitted to MassHealth under the PT-1 program), with Medicare (Medicare guidance is used for Medicare Advantage/OneCare/SCO members where applicable), and with plan-specific variations for OneCare and Senior Care Options (SCO) members. The policy notes that when MassHealth covers a transport via the PT-1 program providers must submit to MassHealth, and for non-emergent transportation beyond 50 miles from the MA border MGB Health Plan policies apply.

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Definitions

Scope Details

Medicare Determinations

NCD: None specific for non-emergent transportation at time of review.

Revision History

2026-01is_materialLatest

2025-09non-material

September 2025: Annual update. Updated code disclaimer.

2024-09is_material

September 2024: Annual update: Clarified language around transport methods. Clarified Medicare variation language. Added MassHealth variation.

Policy Summary

PayerMass General Brigham Health Plan

PolicyNon-Emergency Transportation Medical Necessity Criteria

Policy CodePolicy 037

Change TypeAd hoc and annual updates (2023–2026)

Effective Date

Next Review Date

SourceLink

On This Page

Member's condition has resulted in confinement to the home (homebound) that prevents access via less restrictive transportation.

Member requires skilled care enroute or requires equipment that necessitates ambulance transport (e.g., ventilator, continuous oxygen, IVs).

Member has an orthopedic device(s) and/or orthopedic casting that specifically precludes the member from sitting in a chair car during transport (e.g., backboard, halo-traction, total body cast, hip spicas or other casts that prevent flexion at the hip).

Member has a medical condition which includes any of the following:

Member is medically unstable.
Member requires isolation due to infectious disease.
Member requires special positioning.
Member is at risk of harming themselves or others.
Member requires heavy sedation.
Member has a medical condition that prevents them from performing any physical activity without discomfort.
Member has a medical condition that has resulted in a coma or severe brain damage.

Member is in an isolette (incubator).

There is inadequate time to safely transport the member by land without posing a threat to the member's condition.

Documentation Required

Alternate documentation for members without PCP requirement

For commercial members whose plan does not require a Primary Care Physician/Clinician (PCP), a completed Non-Emergency Medically Necessary Ground Transportation Request form is acceptable in place of the PCS.

Billing Rule

Cost limitation when chair car available

If the member can safely travel by chair car but only an ambulance is available, coverage is limited to the cost of the chair car; the higher ambulance charge will not be allowed. Billing should reflect reimbursement only up to the chair car cost when chair car transport would have been appropriate.

Denial Risk

Claims denial if criteria not met or unlicensed provider

Claims for transportation that do not meet the medical necessity criteria in this policy, or transportation provided by a company that is not licensed or by non-licensed personnel, are excluded and may be denied.

2023-09is_material