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    v1.0.28
    OpenPayerPolicy UpdatesEmergency & Medical TransportationNeighborhood Health Plan RI Non-Emergency Ambulanc…
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    CurrentNeighborhood Health Plan of Rhode IslandPolicy CMP # I-010

    Non-Emergency Ambulance Services

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    Defines medical necessity, coverage criteria, and billing limitations for non-emergency ground and air ambulance transport for Neighborhood Health Plan of Rhode Island members in specified product lines.

    Policy Summary
    PayerNeighborhood Health Plan of Rhode Island
    PolicyNon-Emergency Ambulance Services
    Policy CodePolicy CMP # I-010
    Change TypeNo material changes
    Effective DateJan 1, 2026
    Last ReviewDec 10, 2025
    Next Review DateDec 10, 2025
    Key ActionFor non-emergency transports, obtain and retain a physician's order documenting the member's medical condition and why ambulance transport is required; use Neighborhood's prior authorization forms when applicable.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    A,B,CGround criteria

    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.

    A and (B or C)Air criteria logic
    Not requiredPA for emergent/urgent
    Not coveredAir ambulances (RI Medicaid)
    1 yearPhysician order valid

    Coverage Criteria — Ambulance Transport

    inv-01: Non-emergency ground ambulance — Medically Necessary

    Non-emergency ground ambulance services are considered medically necessary when ALL of the following are met:

    Ground ambulance criteria

    • A. The ambulance must have the necessary equipment and supplies to address the needs of the member.
    • B. The member's condition must be such that any other form of transportation would be medically contraindicated (i.e., the member is bed-confined).
    • C. The requested transfer is from an acute care facility to the member's home.
    Threshold: A and B and C

    inv-02: Non-emergency air ambulance — Medically Necessary

    Non-emergency air ambulance services are considered medically necessary when criterion A is met AND at least one of B or C is present:

    Air ambulance criterion A: A. The time needed to transport the member by land or the instability of transportation by land poses a threat to the member's condition or survival.

    Air ambulance criteria B or C

    • B. The member can't be reached by ground transport.
    • C. Long distances and/or heavy traffic could prevent the member from getting care soon enough if transported by ground.

    inv-03: Deceased members — Criteria when transport for deceased members is considered medically necessary

    Non-emergency ground and air ambulance services for deceased members are considered medically necessary when the above applicable criteria are met AND one of the following is present:

    Deceased member conditions

    • A. The member was pronounced dead while in route or upon arrival at the hospital or final destination.
    • B. The member was pronounced dead by a legally authorized individual (physician or medical examiner) after the ambulance call was made, but prior to pick-up.

    Air ambulances are not covered by Rhode Island Medicaid. This policy follows Rhode Island Medicaid coverage rules and, therefore, Neighborhood Health Plan of Rhode Island does not reimburse air ambulance transports under its Medicaid product line.

    Only the listed modifier combinations are reimbursable. Allowed modifier combinations are: EG, EI, GE, GN, GR, HE, HH, HJ, HN, HR, JE, JN, JR, NG, NH, NJ, NR, RG, RJ; any other modifier combination is not reimbursed.

    Certain items are included in the base transport reimbursement and must not be billed separately. Oxygen, supplies, and EKG services are considered part of the transport payment and are non-billable as separate charges.

    Ambulance transport is covered only when the member's medical condition makes other forms of transportation medically contraindicated. In practice this means the member must be documented as unable to use non-ambulance transport (for example, bed-confined status) and the transport must be to obtain a covered service or to return from one. Absence of documentation that other transportation is contraindicated may render the transport not medically necessary.

    Coding, Modifiers, and Documentation Timeframes

    Allowed ModifiersModifierCovered
    EGEG
    EIEI
    GEGE
    GNGN
    GRGR
    HEHE
    HHHH
    HJHJ
    HNHN
    HRHR
    1–10 of 19
    1/2
    Allowed Modifiers (combined string)ModifierCovered
    EG, EI, GE, GN, GR, HE, HH, HJ, HN, HR, JE, JN, JR, NG, NH, NJ, NR, RG, RJModifier combinations listed as allowable (any other modifier combination is excluded)
    inv-08: Physician order validity for ongoing transport — 1 year
    Validity periodA single physician statement for ongoing non-emergency transport (e.g., dialysis) may be used for up to 1 year.
    Required contentOrder must state the member's medical condition and why ambulance transportation is required.
    Record retentionThe physician's statement must be kept on file by the ambulance provider and be readily available to Neighborhood Health Plan of Rhode Island.
    ScopeApplies to non-emergency ongoing transports only (one statement covers repeated trips for up to one year).

    Provider Actions, Authorization & Documentation

    Prior Authorization

    Prior Authorization Requirements

    Prior authorization is not required for urgent or emergent ambulance transport, including air ambulance. For non-emergency ambulance transports, providers should follow the standard prior authorization process when applicable.

    • Providers: call 1-800-963-1001 or use forms at www.nhpri.org > Providers > Provider Resources > Forms to submit authorization requests.
    • See Authorization Quick Reference Guide for covered codes.
    Documentation Required

    Physician Order Documentation

    Ambulance transport requires a physician's order that documents the member's medical condition and the clinical reason why ambulance transport is required. The order must be maintained on file by the ambulance provider and made readily available to Neighborhood upon request. For ongoing non-emergency transport (e.g., dialysis), a single physician statement may be used for up to one year. Note that the presence or absence of a physician order alone does not determine medical necessity; documentation must support that other forms of transportation are medically contraindicated and that the transport is to obtain or return from a covered service.

    Background

    An ambulance is a specially equipped vehicle staffed and supplied to provide necessary supportive and potentially lifesaving care while transporting a patient to a covered destination. Air ambulances are certified aircraft operated under applicable Federal Aviation Administration standards (Part 135) with compliant crew and maintenance and are subject to separate certification requirements.

    The ambulance’s role is to provide safe, timely transfer when the member’s medical condition precludes use of ordinary transportation. For non-emergency services, a physician’s order must document the member’s medical condition and explain why ambulance transport is required; for ongoing non-emergency transport one order may be valid for up to one year.

    Key Definitions

    inv-16: Bed-confined — definition and criteria
    DefinitionBed-confined: unable to get up from bed without assistance; unable to ambulate; and unable to sit in a chair or wheelchair. Not synonymous with bed rest or nonambulatory.
    Implication for coverageMember's bed-confined status supports that other forms of transportation are medically contraindicated and may justify ambulance transport for non-emergency trips.
    Assessment requirementDocumentation should clearly describe inability to ambulate or sit to demonstrate bed-confined status.
    inv-17: Emergency Ambulance Trip / Emergency Condition — definition and examples
    DefinitionEmergency ambulance trip: an ambulance trip made because of an emergency with destinations including a hospital emergency room, a general hospital or psychiatric facility for a nonscheduled or emergency admission, or transfer to a second facility when emergency services are unavailable at the original site.
    Policy Summary
    PayerNeighborhood Health Plan of Rhode Island
    PolicyNon-Emergency Ambulance Services
    Policy CodePolicy CMP # I-010
    Change TypeNo material changes
    Effective DateJan 1, 2026
    Last ReviewDec 10, 2025
    Next Review DateDec 10, 2025
    Key ActionFor non-emergency transports, obtain and retain a physician's order documenting the member's medical condition and why ambulance transport is required; use Neighborhood's prior authorization forms when applicable.
    SourceLink
    On This Page
    Coverage Criteria — Ambulance TransportCoding, Modifiers, and Documentation TimeframesProvider Actions, Authorization & DocumentationBackgroundKey Definitions
    • Order must state: member's medical condition and specific reason ambulance is required.
    • One physician statement may cover recurring transports for up to one year (e.g., dialysis).
    • Documentation must show that ambulance transport is medically necessary and consistent with the member's diagnosis.
    Denial Risk

    Physician Order and Medical Necessity

    Absence of an appropriate physician order or sufficient medical documentation may result in claim denial. Medical necessity must be demonstrated — the member’s condition must make other transportation options medically contraindicated and the trip must be to obtain a covered service or return from one. Transports that are more costly than bringing the service to the member are not covered.

    • Lack of physician order or inadequate documentation = potential denial.
    • Transport must be to/from a covered service and less costly than alternative arrangements.
    • Type of trip (emergency vs non-emergency) must align with the member's diagnosis.
    Billing Rule

    Provider Requirements

    Ambulance providers/suppliers must comply with all applicable vehicle, staffing, billing, and reporting requirements. Failure to meet these requirements may result in claim denials or payment recoupment. Wheelchair vans are not considered ambulances for the purposes of this policy.

    • Providers must meet vehicle and staffing standards.
    • Claims must follow required billing and reporting rules.
    • Non-qualifying vehicles (e.g., wheelchair vans) are excluded from ambulance reimbursement.
    Billing Rule

    Included Items

    The reimbursement rate for ambulance transport includes certain items and services; these are not reimbursed separately.

    • Oxygen
    • Supplies
    • EKG services
    Emergency condition standardAn emergency condition manifests with acute symptoms of sufficient severity that a prudent layperson could reasonably expect lack of immediate attention to place health in serious jeopardy or result in impairment or dysfunction.
    Behavioral/dental/medical notesEmergency includes behavioral health situations posing imminent risk, dental conditions requiring immediate treatment, and medical conditions with acute severe symptoms (including severe pain).