CurrentOptumPolicy N/A

Ambulance and non-emergency transportation reimbursement

Governs reimbursement for ambulance transportation and related travel/transportation services billed on CMS 1500, UB-04, and electronic claims for Optum-administered behavioral health benefit plans and related products; applies to all network and non-network providers submitting such claims.

Policy Summary

PayerOptum

PolicyAmbulance and non-emergency transportation reimbursement

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProviders must submit accurate claims and coding per CPT/CMS guidance; references are for definitional purposes and do not guarantee reimbursement.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

applies to all productsplan/product scope

CMS 1500, UB-04, 837p/837iclaim form/electronic submission types

20+ codesrepresentative excluded codes

annual No Updatesdocument review history

Excluded Transportation and Ancillary Services

Excluded transportation and ancillary services

Excluded travel or transportation services (representative, not exhaustive):

Services listed below are not considered covered under this policy (representative, not exhaustive).

Examples of excluded travel/transportation services

Travel on a commercial airline or train.
Rental car expenses.
Mileage reimbursement for driving a personal vehicle.

Policy Summary

PayerOptum

PolicyAmbulance and non-emergency transportation reimbursement

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionProviders must submit accurate claims and coding per CPT/CMS guidance; references are for definitional purposes and do not guarantee reimbursement.

SourceLink

On This Page

Representative HCPCS/HCPCS-like codes categorized as not covered

A0080 — Nonemergency transportation, per mile - volunteer vehicle.
A0090 — Nonemergency transportation, per mile - individual with vested interest.
A0100 — Nonemergency transportation; taxi.
A0110 — Nonemergency transportation and bus.
A0130 — Nonemergency transportation: wheelchair van.
A0140 — Nonemergency transportation and air travel.
A0160 — Nonemergency transportation: per mile - caseworker or social worker.
A0170 — Transportation ancillary: parking fees, tolls, other.
A0180 — Nonemergency transportation: ancillary: lodging, recipient.
A0190 — Nonemergency transportation: ancillary: meals, recipient.
A0200 — Nonemergency transportation: ancillary: lodging, escort.
A0210 — Nonemergency transportation: ancillary: meals, escort.
S0209 — Wheelchair van, mileage, per mile.
S0215 — Nonemergency transportation; mileage, per mile.
S9975 — Transplant related lodging, meals, and transportation, per diem.
S9976 — Lodging, per diem, not otherwise specified.
S9992 — Transportation costs for clinical trial participant and caregiver.
S9994 — Lodging costs for clinical trial participant and caregiver.
S9996 — Meals for clinical trial participant and caregiver.
T2001 — Nonemergency transportation; patient attendant/escort.
T2002 — Nonemergency transportation; per diem.
T2003 — Nonemergency transportation; encounter/trip.
T2004 — Nonemergency transport; commercial carrier.
T2005 — Nonemergency transportation; stretcher van.
T2049 — Nonemergency transportation; stretcher van, mileage; per mile.

Representative Non-Covered Transportation Codes

Representative non-covered transportation codesHCPCSNot Covered

A0080	Nonemergency transportation, per mile - volunteer vehicle
A0090	Nonemergency transportation, per mile - individual with vested interest
A0100	Nonemergency transportation; taxi
A0110	Nonemergency transportation and bus
A0120	Nonemergency transportation: mini-bus, mountain area transports, or other transportation systems
A0130	Nonemergency transportation: wheelchair van
A0140	Nonemergency transportation and air travel
A0160	Nonemergency transportation: per mile - caseworker or social worker
A0170	Transportation ancillary: parking fees, tolls, other
A0180	Nonemergency transportation: ancillary: lodging, recipient

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Claims Submission and Coding Responsibility

Billing Rule

Claims Submission and Coding Responsibility

You are responsible for submitting accurate claims that reflect the procedure code(s) that correctly describe the behavioral health services provided to members whose benefits are administered by Optum. This policy uses CPT, CMS and other procedure coding guidelines for definitional purposes; references do not guarantee payment. The policy applies to services billed on the CMS-1500 and, when specified, UB-04 claim forms, and to electronic claim submissions (837P, 837I) and online portal claims. Coding methodology, industry-standard reimbursement logic, regulatory requirements, benefits design, provider contracts and legislative mandates may affect reimbursement and can supplement or supersede this policy. Optum may exercise reasonable discretion in interpreting and applying this policy and implementation may vary across claim processing systems.

Applicable claim forms: CMS-1500, UB-04 (when specified)
Electronic submissions: 837P, 837I, provider portals
Coding references: CPT, CMS and other recognized coding guidelines
Reimbursement influenced by: member benefits, provider contracts, regulatory mandates
Optum may use discretion when applying policy and systems may implement rules differently

Non-Emergent Transportation, Lodging, and Ancillary Travel Expenses

Non-emergent transportation, lodging, and ancillary travel expenses

Policy definitionNon-emergent transportation and housing are generally not considered covered services under this policy; excluded travel and transportation services are listed as examples.

Representative excluded servicesTravel on commercial airline or train; rental car expenses; mileage reimbursement for personal vehicle; lodging; meals; non-emergency ambulance or medical transport; non-emergency transport that accommodates lifters and wheelchairs.

ApplicationApplies to reimbursement related to ambulance transportation and services included as part of an ambulance transportation service for Optum-administered products.

Claim formsExclusions apply to services billed on standard claim forms and electronic submissions (e.g., CMS 1500, UB-04, 837p, 837i) under this policy scope.