CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Non-emergent ambulance transportation prior authorization

Requires prior authorization for specified non-emergent air and ground ambulance services for members enrolled in Neighborhood INTEGRITY for Duals (HMO D-SNP) and Dual CONNECT (HMO D-SNP). Affects providers submitting claims for these products.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyNon-emergent ambulance transportation prior authorization

Policy CodePolicy N/A

Change TypeMaterial coverage additions

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization for A0430, A0431, and A0428 with modifier HR (unless A0428+HR includes a qualifying diagnosis Z74.01, Z99.3, or Z99.11).

SourceLink

POLICY UPDATE CHANGES

Prior authorization is required for certain non-emergent ambulance transportation services for Neighborhood INTEGRITY for Duals and Dual CONNECT effective January 1, 2026.

Air ambulance non-emergent codes A0430 and A0431 now require prior authorization for all covered modifier combinations except listed modifiers.

Ground ambulance non-emergent code A0428 requires prior authorization when billed with modifier HR (Hospital to Residence) unless accompanied by a qualifying diagnosis code.

2Air ambulance codes requiring prior auth

1Ground ambulance code highlighted

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Coverage Criteria

Prior Authorization Criteria

Covered when ALL of the following administrative conditions are met

Product applicability: Member is enrolled in Neighborhood INTEGRITY for Duals (HMO D-SNP) or Dual CONNECT (HMO D-SNP)

Policy applies only to D-SNP products

Air ambulance codes: If billing A0430 or A0431, prior authorization is required unless billed with modifiers HH, SH, II, HI, or IH

All covered modifier combinations except listed modifiers require prior auth

Ground ambulance HR modifier: If billing A0428 with modifier HR, prior authorization is required unless the claim includes one of the qualifying diagnosis codes Z74.01, Z99.3, or Z99.11

A0428 without HR is not addressed by this criterion

This policy applies only to members enrolled in Neighborhood INTEGRITY for Duals (HMO D-SNP) and Dual CONNECT (HMO D-SNP). Emergency ambulance transportation is not affected by the prior authorization requirements described in this policy; emergency transports should continue to be handled according to standard emergency coverage rules.

Claims for services that require prior authorization but are billed without the required prior authorization will be denied. Providers should confirm authorization requirements before submitting claims to avoid denials.

Coding — Affected Codes and Modifiers

Air Ambulance (Non-Emergent)HCPCSCovered

A0430	Air ambulance service, basic life support, non-emergency
A0431	Air ambulance service, advanced life support, non-emergency

Prior Authorization NotemixedCovered

No codes listed

Ground Ambulance (Non-Emergent)HCPCSCovered

A0428

Ambulance service, basic life support, non-emergency transport; ground

Modifier HR (Hospital to Residence) — PA conditionModifierCovered

No codes listed

Modifiers exempt from prior authorization (air ambulance)Modifier

HH	Modifier HH
SH	Modifier SH
II	Modifier II
HI	Modifier HI
IH	Modifier IH

Qualifying Diagnosis Codes (waive prior auth for A0428+HR)ICD-10

Z74.01	Bed confined
Z99.3	Wheelchair dependent
Z99.11	Ventilator dependent

Provider Actions — Authorization & Billing

Prior Authorization

Prior Authorization Required

Prior authorization is required for non-emergent air ambulance services billed with HCPCS codes A0430 and A0431, except when billed with the modifiers listed in the "Modifiers - No Prior Authorization Required" list. Use the Prior Authorization Search Tool to confirm authorization requirements for specific services and follow the tool's instructions to request authorization.

Affected codes: A0430, A0431 (non-emergent air ambulance)
Modifiers that do NOT require prior authorization: HH, SH, II, HI, IH
All other modifier combinations for these codes require prior authorization

Note

Policy Notice

This policy-level requirement applies to Neighborhood INTEGRITY for Duals (HMO D-SNP) and Dual CONNECT (HMO D-SNP) members effective 2026-01-01. Emergency ambulance transportation is not affected.

Note

Background

This policy establishes administrative prior authorization requirements for certain non-emergent ambulance transportation services for Neighborhood D-SNP members. It is an administrative policy change only and does not alter clinical definitions of emergency transport; emergency ambulance transportation remains unaffected. The requirement aligns with the D-SNP member benefit package and applies exclusively to Neighborhood D-SNP products.

Definitions

Modifier HR

Modifier nameHR (Hospital to Residence)

When it appliesUsed with ground ambulance code A0428 to indicate Hospital to Residence transport

Authorization ruleA0428 billed with modifier HR requires prior authorization unless the claim includes one of the qualifying diagnosis codes Z74.01, Z99.3, or Z99.11

Qualifying diagnosis codes

Z74.01Bed confined — exempts A0428+HR from prior authorization

Z99.3Wheelchair dependent — exempts A0428+HR from prior authorization

Z99.11