Non-Emergent Ambulance Transportation Prior Authorization Requirement
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Requires prior authorization for certain 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 members.
Effective January 1, 2026, Neighborhood requires prior authorization for certain non-emergent ambulance transportation services for members enrolled in Neighborhood INTEGRITY for Duals (HMO D-SNP) and Dual CONNECT (HMO D-SNP).
Prior authorization is required for air ambulance codes A0430 and A0431 for all covered modifier combinations except specified modifiers.
Prior authorization is required for ground ambulance code A0428 with modifier HR (Hospital to Residence) when billed without specified qualifying diagnosis codes.
Claims billed without required prior authorization will be denied.
Prior Authorization Coverage Criteria
Prior Authorization Criteria
Prior authorization rules for non-emergent ambulance services for Neighborhood D-SNP members:
Air ambulance A0430/A0431
Ground ambulance A0428 with HR
- Prior authorization is required when A0428 is billed with modifier HR (Hospital to Residence) unless the claim includes one of the qualifying diagnosis codes Z74.01, Z99.3, or Z99.11.
Qualifying diagnosis codes (waive PA for A0428+HR)
- Z74.01 - Bed confined
- Z99.3 - Wheelchair dependent
- Z99.11 - Ventilator dependent
Codes, Modifiers, and Qualifying Diagnoses
| A0428 | Ground ambulance (basic life support) — prior authorization required when billed with modifier HR unless claim includes a qualifying diagnosis code |
| Z74.01 | Bed confined |
| Z99.3 | Wheelchair dependent |
| Z99.11 | Ventilator dependent |
What Providers Must Do
Require Prior Authorization for Non‑Emergent Ambulance (D‑SNP only)
Effective January 1, 2026, prior authorization is required for certain non-emergent ambulance transports for members enrolled in Neighborhood INTEGRITY for Duals (HMO D-SNP) and Dual CONNECT (HMO D-SNP). Specifically, prior authorization is required for air ambulance codes A0430 and A0431 for all covered modifier combinations except the exempt modifiers, and for ground ambulance code A0428 when billed with modifier HR unless the claim includes one of the qualifying diagnosis codes Z74.01, Z99.3, or Z99.11. Claims billed without required prior authorization will be denied. This requirement applies only to Neighborhood D-SNP products; emergency ambulance transportation is not affected. Providers should use the Prior Authorization Search Tool and the Non-Emergency Ambulance Services Clinical Medical Policy for guidance.
- Air ambulance codes A0430 and A0431 require prior authorization for all covered modifier combinations except those specifically exempted. [[see source]]
- Ground ambulance code A0428 requires prior authorization when billed with modifier HR unless billed with one of: Z74.01, Z99.3, or Z99.11.
- Claims without required prior authorization will be denied.
- Requirement effective 2026-01-01 and applies only to Neighborhood D-SNP products; emergency transports are excluded.
- Use the Prior Authorization Search Tool and refer to the Non-Emergency Ambulance Services Clinical Medical Policy for details.
Key Definitions and Modifier Details
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