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    v1.0.30
    OpenPayerPolicy UpdatesEmergency & Medical TransportationMass General Brigham Transport Coverage | OpenPaye…
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    ModifiedMass General Brigham Health PlanPolicy 037

    Medical Necessity Guidelines Non-Emergency Transportation

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    This policy governs medical necessity and coverage requirements for non-emergency ground ambulance, chair car, interfacility ground, and interfacility air/sea ambulance transportation. It applies to Mass General Brigham Health Plan members and varies by line of business, with prior authorization generally required except where specifically stated.

    Policy Summary
    PayerMass General Brigham Health Plan
    PolicyMedical Necessity Guidelines Non-Emergency Transportation
    Policy CodePolicy 037
    Change TypeModified
    Effective DateNov 1, 2026
    Last ReviewNov 1, 2026
    Next Review DateN/A
    Key ActionObtain prior authorization for covered transportation when required by the member's plan and applicable policy criteria.
    SourceLink
    POLICY UPDATE CHANGES

    The policy added plan-specific variations for One Care and Senior Care Options members.

    The policy clarified coverage of chair car services for One Care and Senior Care Options members.

    The policy added a reference to MassHealth transportation services regulations.

    The policy added information about non-emergency non-medical transportation for One Care and Senior Care Options members.

    The policy expanded the listed ground ambulance medical necessity criteria to include additional clinical circumstances and isolette transport.

    The policy clarified that transportation from a facility to a member's residence may be covered under specified circumstances.

    The policy clarified that interfacility transportation must use the least intensive transportation method that meets the member's condition.

    The policy history records an update to the prior authorization table and the addition of coverage variations for One Care and Senior Care Options members.

    The policy history records clarification of coverage language for transport methods and Medicare and MassHealth variations.

    The policy history records the addition of criteria concerning interfacility transfers and transportation from a facility to a member's residence under certain circumstances.

    The policy history records removal of an exclusion concerning discharge-to-home transportation.

    The policy history records clarification that repatriation and transportation solely for convenience are excluded.

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    4Transportation service categories addressed
    Generally requiredAuthorization status
    Least intensiveTransportation selection standard
    50 milesACO geographic boundary
    13Exclusion categories

    Non-Emergency Transportation Coverage Criteria

    Non-emergency medically necessary ground ambulance

    Covered when all of the following are met:

    Ground ambulance criteria

    • Required conditions

      • The member is receiving a covered medically necessary service.
      • The member's medical condition prevents safe transportation by any other means, such as a chair car, and ground ambulance is the least intensive medically necessary method.
      • The member's condition does not allow access to a less restricted method of transportation normally used to access the community, such as a personal vehicle, taxi, public transportation, or walking.

    • At least one additional criterion

      • The member is bed confined and unable to sit in a chair or wheelchair, including following cardiac catheterization at an outside facility.
      • The member is confined to a wheelchair and resides in a home that prevents access by less restrictive transportation.
      • The member is homebound because of a condition that prevents access by less restrictive transportation.
      • The member requires skilled care en route or equipment that necessitates ambulance transport, such as a ventilator, continuous oxygen, or intravenous therapy.
      • The member has an orthopedic device or cast that specifically prevents sitting in a chair car, such as a backboard, halo-traction, total body cast, hip spica, or another cast that prevents hip flexion.

      • Qualifying medical condition

        • The member is medically unstable.
        • The member requires isolation because of an infectious disease.
        • The member requires special positioning.
        • The member is at risk of harming themselves or others.
        • The member requires heavy sedation.
        • The member has a medical condition that prevents any physical activity without discomfort.
        • The member has a medical condition resulting in coma or severe brain damage.
      • The member is being transported in an isolette or incubator.

    Non-emergency medically necessary chair car

    Covered when all of the following are met:

    Chair car criteria

    • The member is receiving a covered medically necessary service.
    • The member's medical condition prevents safe transportation by any other means and chair car is the least intensive medically necessary method.

    • At least one additional criterion

      • The member's condition does not allow access to a less restricted method of transportation normally used to access the community, such as a personal vehicle, taxi, public transportation, or walking.
      • The member cannot safely transfer from a wheelchair to a vehicle, with or without assistance.

    Non-emergency medically necessary interfacility air or sea ambulance

    Covered when at least one criterion is met:

    At least one interfacility air or sea ambulance criterion

    • Medical attention during transport

      • The member's medical condition requires medical attention during transport.

      • Ground transportation is not appropriate or accessible

        • Ground transportation is contraindicated or inappropriate to ensure the member's safe transfer.
        • A ground ambulance cannot access the member because the pickup point is not accessible by a land vehicle.
    • The member received urgent or emergency care outside the service area, is medically stable for transport back to the plan service area, and requires medical attention during transport to ensure a safe return. The health plan determines whether transport back into the plan service area is medically necessary and appropriate.

    Non-emergency medically necessary interfacility ground transportation

    Covered when all of the following are met:

    Interfacility ground transportation criteria

    • The plan has authorized the admission.

    • The service necessitating transportation is clinically related to the admission

      • The service is related to the member's current reason for care.
      • The service is pertinent to advancement of the member's care.
      • The service is a diagnostic service that could cause harm if delayed until after discharge.
    • The least intensive type of transportation that meets the member's medical condition is used, regardless of availability.

    ACO geographic variation

    Mass General Brigham ACO geographic variation:

    Applicable geographic rule

    • For Mass General Brigham ACO members, non-emergent transportation within Massachusetts and out-of-state transportation up to 50 miles from the Massachusetts border is covered directly by MassHealth.Up to 50 miles from the Massachusetts border
    • For non-emergent transportation that begins or ends more than 50 miles from the Massachusetts border, Mass General Brigham Health Plan policies apply.More than 50 miles from the Massachusetts border

    One Care and SCO transportation benefit

    One Care and SCO members have the following transportation benefit:

    CTS transportation benefit

    • Non-emergent non-medical and medical transportation is covered through contracted provider CTS when booked through CTS. Covered transportation may include non-emergent ambulance, taxi livery, a transportation network company such as Uber or Lyft, wheelchair-accessible vehicle, stretcher van, or ferry.

      This benefit does not require authorization from Mass General Brigham Health Plan, and this policy's medical necessity criteria do not apply. See the Member Handbook, Chapter 4, for service limits and details.

    Non-emergency interfacility air/sea ambulance

    Covered when prior authorization is obtained and the applicable medical necessity criteria are met:

    Interfacility air/sea ambulance requirements

    • Prior authorization is obtained.
    • The applicable medical necessity criteria for non-emergency medically necessary interfacility air or sea ambulance transportation are met.

    Transportation is excluded when it does not meet the applicable coverage criteria, is provided by an unlicensed company or non-licensed personnel, or is used to obtain a service that is not covered by the health plan.

    Waiting time is excluded. Ambulance, air, or sea transportation is also excluded when the member can safely use an alternative transportation method without endangering the member’s health, regardless of whether the less intensive method is actually available.

    Transportation to or from child day-care centers, nurseries, schools, summer camps, recreational programs, pharmacies to obtain medications, adult day health programs, or government agency offices is excluded.

    The policy excludes taxi or public transportation; ancillary fees such as parking, tolls, and other associated charges; lodging or meals for the member or an escort; transport of a patient who was deceased before the ambulance was called; repatriation from another country to the United States; and non-emergency air or sea ambulance transportation that is not qualifying interfacility transportation to the nearest appropriate facility.

    Transportation selected solely for the convenience or preference of the member, provider, facility, staff, family, or authorized representative is excluded.

    The least intensive transportation method that safely meets the member’s medical condition must be used. A more intensive method is not medically necessary when the member can safely use a different method, even if the less intensive method is unavailable. For example, when a member can safely travel by chair car but only an ambulance is available, coverage is limited to the chair car cost.

    Interfacility transportation is not medically necessary for routine visits, examinations, or preventive health care services that are unrelated to the care and treatment of the member’s current admission.

    Authorized Transportation Codes

    Authorized CodesHCPCS
    A0130Nonemergency transportation: wheelchair van.
    A0140Nonemergency transportation and air travel (private or commercial) intra- or interstate.
    A0426Ambulance service, advanced life support, nonemergency transport, level 1 (ALS 1).
    A0428Ambulance service, basic life support, nonemergency transport, (BLS).
    A0434Specialty care transport (SCT).
    A0380BLS mileage (per mile).
    A0425Ground mileage, per statute mile.
    A0430Ambulance service, conventional air services, transport, one way (fixed wing).
    A0431Ambulance service, conventional air services, transport, one way (rotary wing).
    A0435Fixed wing air mileage, per statute mile.
    1–10 of 12
    1/2
    Authorized CodeHCPCS
    A0130Nonemergency transportation: wheelchair van.
    A0140Nonemergency transportation and air travel (private or commercial) intra- or interstate.
    A0426Ambulance service, advanced life support, nonemergency transport, level 1 (ALS 1).
    A0428Ambulance service, basic life support, nonemergency transport (BLS).
    A0434Specialty care transport (SCT).
    A0380BLS mileage (per mile).
    A0425Ground mileage, per statute mile.
    A0430Ambulance service, conventional air services, transport, one way (fixed wing).
    A0431Ambulance service, conventional air services, transport, one way (rotary wing).
    A0435Fixed wing air mileage, per statute mile.
    1–10 of 12
    1/2

    Authorization, Documentation, and Denial Risks

    Prior Authorization

    Plan-Specific Prior Authorization Required

    Prior authorization is required for non-emergency transportation under the applicable plan-specific rules. Apply the governing criteria and guidance for the member’s line of business before arranging transportation.

    • Medicare Advantage: Prior authorization is required; CMS guidance applies, including applicable NCDs, LCDs, LCAs, and Medicare manuals.
    • Mass General Brigham ACO: Prior authorization is required; MassHealth guidance applies. MassHealth directly covers qualifying transportation within Massachusetts and up to 50 miles from the Massachusetts border; Mass General Brigham Health Plan policy applies when transportation begins or ends more than 50 miles from the border.
    • One Care and SCO: Prior authorization is required when requesting transportation under this policy; CMS criteria apply first, followed by MassHealth criteria when applicable.
    • Commercial and Qualified Health Plans: Prior authorization is required.

    Policy Background

    Non-emergency transportation may be covered when the member’s condition makes other transportation methods unsafe or contraindicated. The selected method must be the least intensive medically necessary option that meets the member’s clinical needs, including requirements for mobility assistance, positioning, equipment, monitoring, or care during transport.

    Transportation Terms

    Chair Car
    Vehicle typeA wheelchair van or motorized vehicle specifically equipped to carry a person with mobility limitations or who uses a wheelchair.
    Intended useTransportation of sick, injured, or disabled persons.
    Operating requirementsThe vehicle must be maintained and operated for this transportation purpose and have a valid certificate of inspection and license.
    Emergency Medical Condition
    ConditionA physical or mental medical condition manifesting with symptoms of sufficient severity, including severe pain.
    Prompt attentionA prudent layperson with average knowledge of health and medicine could reasonably expect that absence of prompt medical attention would place the individual's health in serious jeopardy.
    Policy Summary
    PayerMass General Brigham Health Plan
    PolicyMedical Necessity Guidelines Non-Emergency Transportation
    Policy CodePolicy 037
    Change TypeModified
    Effective DateNov 1, 2026
    Last ReviewNov 1, 2026
    Next Review DateN/A
    Key ActionObtain prior authorization for covered transportation when required by the member's plan and applicable policy criteria.
    SourceLink
    On This Page
    Non-Emergency Transportation Coverage CriteriaAuthorized Transportation CodesAuthorization, Documentation, and Denial RisksPolicy BackgroundTransportation Terms
  1. There is inadequate time to safely transport the member by land without posing a threat to the member's condition.

    2. No separate authorization is required for the interfacility transportation itself. When the member can travel by chair car and only an ambulance is available, coverage is limited to the cost of the chair car.

    Billing Rule

    Participating Provider and Nearest Appropriate Facility

    Use participating transportation providers and transport the member to the nearest appropriate facility capable of providing the medically necessary care. An out-of-network transportation service may be authorized only when no participating transportation service is available.

    Note

    Authorized-Admission Exception for Interfacility Ground Transport

    For non-emergency medically necessary interfacility ground transportation, including ground ambulance and chair car, no separate transportation authorization is required when Mass General Brigham Health Plan has authorized the admission and the transportation meets the applicable medical-necessity criteria.

    • The service must relate to the current reason for care, advance the member’s care, or be a diagnostic service that could cause harm if delayed until after discharge.
    • Use the least intensive transportation method that meets the member’s condition, regardless of availability.
    Prior Authorization

    Air and Sea Ambulance: Authorization and Medical Necessity

    Obtain authorization and establish medical necessity before arranging non-emergency interfacility air or sea ambulance transportation. The transport must be medically necessary to a covered, authorized, medically appropriate facility and meet the applicable clinical criteria.

    • Covered destinations include an acute medical hospital, acute rehabilitation hospital, skilled nursing facility, or long-term acute care facility.
    • The member must require medical attention during transport and either ground transport is contraindicated or inappropriate, the pickup point is inaccessible by ground ambulance, or safe land transport would take too long and threaten the member’s condition.
    • An ill or injured member treated urgently or emergently outside the service area may be transported back to the plan service area when medically stable but requiring medical attention during transport, as determined appropriate by the health plan.
    Prior Authorization

    Prior Authorization Required for Interfacility Air/Sea Ambulance

    Non-emergency interfacility air or sea ambulance transportation is covered only when prior authorization has been obtained, the transportation is to the nearest appropriate facility capable of providing the medically necessary services, and all applicable criteria are met.

    • Air or sea ambulance services outside interfacility transportation are excluded.
    • See the applicable authorization and documentation requirements before transport.
    Documentation Required

    Submit the Required Certification Form

    When Mass General Brigham Health Plan requires prior authorization, submit a completed Physician Certification Statement (PCS) for Non-Emergency Ambulance Services for all non-emergency ground, sea, and air transportation. The PCS must provide the information needed to determine medical necessity.

    • For commercial members whose plan does not require a Primary Care Physician/Clinician, a completed Non-Emergency Medically Necessary Ground Transportation Request form may be accepted instead of the PCS.
    • Use the applicable Non-Emergency Medically Necessary Ground Transportation Request Form when required.
    Documentation Required

    Documentation Must Be Legible and in English

    All submitted transportation documentation must be legible and in English.

    Documentation Required

    Personnel and Vehicle Requirements

    The driver or pilot must hold a valid license as a medically trained professional consistent with the type of transportation required, and the vehicle must have the appropriate technology to treat the member during transport.

    • Verify licensing and medical-training requirements for the personnel providing the service.
    • Verify that the vehicle is equipped for the member’s required level of care.
    Denial Risk

    Failure to Meet Medical Necessity or Licensing Requirements

    Transportation may be denied when the service is not medically necessary or reasonable, when the member’s condition does not require the requested level of transport, or when the provider, personnel, or vehicle fails applicable licensing or qualification requirements.

    • Medical necessity requires that the member’s condition contraindicates use of another transportation method.
    • Transportation provided by an unlicensed company or non-licensed personnel is excluded.
    • All transportation that fails the applicable medical-necessity criteria is excluded.
    Denial Risk

    More Intensive Transportation Than Medically Necessary

    Use the least intensive transportation method that safely meets the member’s condition. The plan may deny the incremental cost or the entire service when a less intensive method could safely be used, even if the less intensive vehicle is unavailable.

    • Ambulance, air, or sea transport is excluded when an alternative method is available and can be used without endangering the member.
    • If the member can travel by chair car but only an ambulance is available, coverage is limited to the chair-car cost; the higher ambulance charge is not covered.
    • Transportation must be appropriate to the member’s actual clinical needs, not selected for convenience or preference.
    Denial Risk

    Routine or Preventive Interfacility Services Excluded

    Interfacility transportation is not covered when it is for routine visits, examinations, or preventive health care services that are not pertinent to the care and treatment of the member’s current admission.

    • Confirm that the service is related to the current admission, advances the member’s care, or is a diagnostic service that could cause harm if delayed until after discharge.
    Denial Risk

    Excluded Transportation and Ancillary Charges

    The plan excludes transportation that does not meet the policy criteria, is for a non-covered purpose or destination, or includes excluded methods and ancillary charges.

    • Excluded purposes or destinations include child day-care centers or nurseries, schools, summer camps, recreational programs, pharmacies to obtain medications, adult day health programs, government agency offices, and locations used solely for the convenience or preference of the member, provider, facility, staff, family, or authorized representative.
    • Excluded services include taxi or public transportation, transportation to a destination or for services not covered by the health plan, repatriation from another country to the United States, and transport of a deceased patient to a coroner’s office or mortuary.
    • Excluded charges include waiting time, parking fees, tolls, and lodging or meal expenses for the member or an escort.
    • Non-emergency air or sea ambulance is excluded unless it is interfacility transportation to the nearest appropriate facility providing medically necessary services.

    Unsupported block type: info

    Billing Rule

    Code Listing Does Not Guarantee Coverage

    The codes listed in this policy are provided for informational purposes only. Inclusion of a code does not constitute or imply that the service is covered or that reimbursement is guaranteed.

    • Coverage and reimbursement remain subject to the member’s benefit, applicable authorization requirements, medical-necessity criteria, exclusions, and all other plan rules.
    Potential consequencesThe condition could result in serious impairment to body function or serious dysfunction of any body organ or part; for a pregnant woman, this includes the health of the woman or her unborn child.
    Ground, Sea, and Air Ambulance Transportation
    Transportation meansAn aircraft, boat, motor vehicle, or other means of transportation, including a dual-purpose vehicle, whether privately or publicly owned.
    Intended useTransportation of sick or injured persons.
    Operating requirementsThe transportation means must be maintained and operated for this purpose and have a valid certificate of inspection and license.
    Interfacility
    Sending facilityAn acute medical hospital, acute rehabilitation hospital, long-term acute care (LTAC) facility, or skilled nursing facility (SNF).
    Receiving facilityAnother acute medical hospital, acute rehabilitation hospital, LTAC facility, or SNF.
    Provider numbersThe sending and receiving facilities must have different provider numbers.