CurrentNeighborhood Health Plan of Rhode IslandPolicy CMP # I-010

Non-Emergency Ambulance Services

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

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

A and (B or C)Air criteria logic

Not requiredPA for emergent/urgent

Not coveredAir ambulances (RI Medicaid)

1 yearPhysician order valid

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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

EG	EG
EI	EI
GE	GE
GN	GN
GR	GR
HE	HE
HH	HH
HJ	HJ
HN	HN
HR	HR

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, RJ

Modifier 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.