CurrentMass General Brigham Health PlanPolicy N/A

Non-Emergency Medically Necessary Ground Transportation

Defines coverage requirements and documentation for non-emergency medically necessary ground transportation for Commercial members of Mass General Brigham Health Plan; excludes MassHealth members. Specifies that services must be medically necessary, provided by contracted ambulance providers, and requires a completed form with member, trip, and signer information.

Policy Summary

PayerMass General Brigham Health Plan

PolicyNon-Emergency Medically Necessary Ground Transportation

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionUse contracted ambulance providers and submit the completed non-emergency ground transportation form with required clinical documentation showing other transport methods are contraindicated.

SourceLink

POLICY UPDATE CHANGES

No material changes to policy coverage or clinical criteria.

CommercialApplicable Population

MassHealthExcluded Population

ContractedProvider Requirement

Coverage Summary

Defines coverage requirements and documentation for non-emergency medically necessary ground transportation for Commercial members of Mass General Brigham Health Plan; excludes MassHealth members. Coverage requires that services be medically necessary (patient's condition contraindicates other transportation methods), provided by contracted (participating) ambulance providers, and supported by a completed transport request form capturing member, trip, and signer information.

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Medical Necessity Criteria

Coverage / Medical Necessity

Covered when ALL of the following are met:

ALL of the following

Commercial member limitation: Member is a Commercial member of Mass General Brigham Health Plan (coverage does not apply to MassHealth members).
Non-emergency ground transport to nearest capable location: Transportation is non-emergency ground transportation to the nearest location capable of providing the medically necessary care required by the member.
Medical necessity defined: Medical necessity is established when the patient's condition is such that the use of any other method of transportation is contraindicated.
Contracted ambulance provider: Services are provided by a contracted (participating) ambulance provider listed by Mass General Brigham Health Plan.
Completed transportation request form: A completed transportation request form with required member, trip, and signature fields is submitted.

Provider Actions & Requirements

Prior Authorization

Use contracted ambulance providers

Services must be provided by contracted (participating) ambulance providers. The provider should confirm the ambulance service is contracted — a list of contracted ambulance providers is available on the Mass General Brigham Health Plan website.

Documentation Required

Complete and submit required transport request form

Complete and submit the non-emergency ground transportation form. Required elements include member information, requested service and trip details, dates of service, destination information, the ambulance/chair car servicing provider, and required signatures.

Documentation Required

Establish medical necessity in chart

Clinical documentation in the medical record must establish medical necessity by showing the patient's condition contraindicates the use of any other method of transportation.

Background

Mass General Brigham Health Plan covers non-emergency medically necessary transportation services to the nearest location capable of providing the required medically necessary care when other methods of transportation are contraindicated. Coverage requires use of contracted (participating) ambulance providers and submission of the required transport request form and related documentation to support claims processing.

Medical necessity: Patient's condition is such that the use of any other method of transportation is contraindicated.