Modifiedpriority healthPolicy N/A

Ambulance services coverage and reimbursement

Defines Priority Health's coding, documentation, authorization, and reimbursement rules for ambulance transport, stabilization (non-transport), and related billing for commercial, Medicare, and Medicaid members in North Carolina.

Policy Summary

Payerpriority health

PolicyAmbulance services coverage and reimbursement

Policy CodePolicy N/A

Change TypeMaterial updates to modifier and diagnostic guidance

Effective DateN/A

Next Review DateMar 1, 2026

Key ActionObtain prior authorization for all fixed‑wing transports; claims without required origin/destination modifiers may be denied.

SourceLink

POLICY UPDATE CHANGES

Added a large list of origin and destination modifiers that are not payable for transportation.

Clarified that Priority Health will follow CMS and MDHHS diagnostic criteria for ambulance services.

Removed 'applies to' language from the policy.

A0425–A0436HCPCS codes listed

Fixed‑wingAuthorizations required

A0998Stabilization covered

manyNot‑payable modifiers

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Diagnostic alignment

Ambulance Coverage Criteria

Ambulance coverage criteria

Priority Health covers medically necessary ambulance services with specific rules and exclusions.

ALL of the following

Covered to the nearest facility able to provide emergency care; payment is based on the level of service provided and must be supported by documentation.
Medicare: payable only when beneficiary's medical condition makes other means of transportation contraindicated and documentation supports the level of service provided.

ALL of the following

Covered without prior authorization for non-emergent transportation including medically necessary interfacility transfers.
Fixed-wing transports require prior authorization; fixed-wing and non-emergency services not authorized in advance are not payable.

ALL of the following

Covered for Commercial, Medicare, and Medicaid members; bill A0998 for response and treatment with no transport.
Do NOT append an origin/destination modifier to A0998 (stabilization non-transport).

ALL of the following

Origin and destination modifiers are required on transport claims; missing or disallowed modifiers will result in denial.
Claims using the listed origin/destination modifiers (DD, DE, DG, DJ, DP, DS, ED, EE, EP, ES, GD, GG, GJ, GP, GS, HP, HS, ID, IE, IG, IJ, IN, IP, IR, IS, JD, JJ, JP, JS, NP, NS, PD, PE, PG, PJ, PP, PR, PS, RD, RE, RP, RR, RS, SD, SE, SG, SJ, SN, SP, SR, SS, XD, XE, XG, XH, XI, XJ, XN, XP, XR, XS, XX) are not payable for transportation.

ALL of the following

Ambulance services are not separately payable when provided within inpatient admission/discharge dates (bundled), except day of admission/discharge; SNF resident transports are not separately reimbursed.

ALL of the following

Services must meet ICD-10-CM diagnostic criteria and level of service per CMS and MDHHS; primary diagnosis must describe condition at transport and documentation must support billed level of service.

ANY of the following

Fixed-wing and non-emergency ambulance services not authorized in advance are not payable.
Claims missing required codes or modifiers are not payable.
Claims with any submitted diagnosis code described as 'unspecified' are not payable.
Claims using the listed origin/destination modifiers are not payable.

ALL of the following

ESRD non-emergency BLS transports to/from dialysis receive payment adjustments; use modifiers to indicate hospital-based (G) or freestanding (J) facility type and institutional claims should use revenue code 0540.

ALL of the following

Equipment, supplies, or services reported with an ambulance transport code on the same date are not separately payable and are included in the transport payment rate.

ALL of the following

Medicaid may cover EMT/ambulance treatment on scene without transport; refer to the Medicaid Provider Manual for details.

ALL of the following

Priority Health may perform pre- or post-claim reviews and may reject, deny, or recoup payments if billing, coding, authorization, or documentation requirements are not met.

ALL of the following

No payment for mileage beyond the closest appropriate facility; miles beyond should be billed with A0888. Exception: CAH claims reporting condition code B2 per policy.

ALL of the following

Ambulance services should be coded with POS 41 (land) or POS 42 (air/water); coverage considered for services furnished in appropriate setting to the patient's needs; authorization may be required.

ALL of the following

For rural/super rural transports the TN modifier must be reported in addition to origin/destination modifiers; reimbursement may be adjusted based on pickup ZIP code.

ALL of the following

Authorization does not guarantee payment; proper CPT/HCPCS/revenue codes and documentation to highest specificity are required; failure to document will result in denial.

ALL of the following

Related denial language: E4M - Not a covered service.

ALL of the following

Priority Health follows CMS and MDHHS diagnostic criteria for ambulance transports.

ALL of the following

Emergent transport is payable when correctly authorized (if necessary) and when the correct origin and destination modifier combination is submitted with the procedure code.

ALL of the following

For ambulance stabilization non-transport services, do NOT include a modifier.

ALL of the following

Claims lacking required codes/modifiers or submitted with unspecified diagnosis descriptions will be denied as not payable.

ALL of the following

Medicare coverage requires beneficiary condition to contraindicate other transport means and documentation supporting medical necessity and level of service.

ALL of the following

Prior authorization is required for fixed-wing transports (emergent and non-emergent). Authorization is not required for emergency ground and helicopter services and for ambulance stabilization non-transport for Priority Health Medicare Advantage members.

Ambulance coverage criteria

Coverage and payment conditions for ambulance services

ALL of the following

Payment allowed when ambulance transport is medically necessary and the level of care provided justifies transport; no payment if the individual could have been safely transported by another means.

ALL of the following

Priority Health follows CMS and MDHHS diagnostic criteria for ambulance transports.

ALL of the following

Emergent transport is payable when correctly authorized, if necessary, and when the correct origin/destination modifier combination is submitted with the procedure code.

ALL of the following

Codes, Modifiers, and Mileage

Ambulance HCPCS codesHCPCSCovered

A0425	Ground mileage, per statute mile
A0426	Ambulance service, advanced life support, non-emergency transport, level 1 (ALS1)
A0427	Ambulance service, advanced life support, emergency transport, level 1 (ALS1Emergency)
A0428	Ambulance service, basic life support, non-emergency transport (BLS)
A0429	Ambulance service, basic life support, emergency transport (BLS-Emergency)
A0433	Advanced life support, level 2 (ALS2)
A0434	Specialty care transport (SCT)
A0435	Fixed wing air mileage, per statute mile
A0436	Rotary wing air mileage, per statute mile
A0430	Ambulance service, conventional air services, transport, one way (fixed wing)

1–10 of 13

1/2

Place of Servicemixed

POS 41	Ambulance -Land
POS 42	Ambulance -Air or Water

Not-payable origin/destination modifiersModifierNot Covered

DD, DE, DG, DJ, DP, DS, ED, EE, EP, ES, GD, GG, GJ, GP, GS, HP, HS, ID, IE, IG, IJ, IN, IP, IR, IS, JD, JJ, JP, JS, NP, NS, PD, PE, PG, PJ, PP, PR, PS, RD, RE, RP, RR, RS, SD, SE, SG, SJ, SN, SP, SR, SS, XD, XE, XG, XH, XI, XJ, XN, XP, XR, XS, XX

Origin and destination modifiers listed as not payable for transportation

Mileage payment limit

Payment limitNo payment for mileage beyond the closest appropriate facility; bill A0888 for excess miles.

Exception for CAHCritical Access Hospital claims reporting condition code B2 may attest no other ambulance provider within 35-mile drive.

Related HCPCSReport A0425 for ground mileage; use A0888 to report non-covered excess miles.

Bundling noteMileage included with transport payment when supplies/equipment reported on same date; follow bundling guidelines.

Medically necessary transport standard

Medically necessary standard

Authorization, Documentation, and Billing Actions

Prior Authorization

Prior Authorization Required for Fixed‑Wing Transports

Prior authorization is required for fixed-wing (air) transports, both emergent and non-emergent. Providers must obtain authorization in advance for these services to avoid payment denial.

Applies to fixed‑wing transports (emergent and non‑emergent)

Documentation Required

Medicare PSOD Requirement

For Medicare members, when an indication does not meet NCD, LCD, or specific medical policy criteria, a Pre‑Service Organization Determination (PSOD) must be completed prior to service.

Medicare PSOD required if NCD/LCD/policy criteria not met
See Priority Health PSOD guidance for submission details

Definitions and Place of Service

Ambulance; Emergent transportation; Ambulance stabilization

Ambulance (definition)A motor vehicle or aircraft primarily used to provide transportation and basic life support (BLS), limited advanced life support, or advanced life support.

Emergent transportationDefined as dispatched by a 911 call, whether or not the patient agrees to be taken to the hospital.

Ambulance stabilization (non-transport)An ambulance response where the patient is treated and stabilized on scene but no transport is made; do not include origin/destination modifier for stabilization non-transport.

Ambulance - Land

POS 41Ambulance - Land (use POS 41 for land ambulance services)

Coding guidanceAmbulance services should be coded with POS 41 when furnished in a land setting appropriate to the patient's needs.

Policy Summary

Payerpriority health

PolicyAmbulance services coverage and reimbursement

Policy CodePolicy N/A

Change TypeMaterial updates to modifier and diagnostic guidance

Effective DateN/A

Next Review DateMar 1, 2026

Key ActionObtain prior authorization for all fixed‑wing transports; claims without required origin/destination modifiers may be denied.

SourceLink

On This Page

For ambulance stabilization non-transport services, do NOT include a modifier.

ALL of the following

Fixed-wing and non-emergency ambulance services not authorized in advance are not payable.

ALL of the following

Claims using the listed origin/destination modifiers are not payable for transportation.

ALL of the following

Claims missing required codes or modifiers, or with any submitted diagnosis described as 'unspecified', are not payable.

ALL of the following

Ambulance services should be coded with POS 41 (land) or POS 42 (air/water); coverage considered for services furnished in appropriate setting; authorization may be required.

ALL of the following

For rural/super rural transports the TN modifier must be reported in addition to origin/destination modifiers; reimbursement may be adjusted based on pickup ZIP code.

ALL of the following

Related denial language: E4M - Not a covered service.

ALL of the following

Authorization does not guarantee payment; correct CPT/HCPCS/revenue codes and documentation to highest specificity are required; failure to document will result in denial.

ALL of the following

Priority Health may perform pre- or post-claim payment integrity reviews and may reject, deny, or recoup payments if guidelines are not followed.

ALL of the following

Fixed-wing and non-emergency ambulance services not authorized in advance are not payable.

ALL of the following

Claims using the listed origin/destination modifiers (see policy) are not payable for transportation.

ALL of the following

No payment allowed for mileage beyond the closest appropriate facility; excess miles should be billed with A0888.

ALL of the following

Authorization may be required for certain transports; when required, lack of prior authorization will make the service not payable.

ALL of the following

For ambulance stabilization non-transport services, do NOT include a modifier.

ALL of the following

POS 41 for land and POS 42 for air/water should be used on claims for ambulance services.

ALL of the following

Report TN modifier in addition to origin/destination modifiers for rural/super rural transports; reimbursement may be adjusted based on Point of Pick-up ZIP code.

ALL of the following

Claims may be denied when required authorization is missing, codes/modifiers are missing, unspecified diagnoses are present, or disallowed modifiers are used.

ALL of the following

Priority Health may conduct reviews and recoup payments if billing or documentation requirements are not met.

ALL of the following

Emergent transport is payable when correctly authorized, if necessary, and when the correct origin and destination modifier combination is submitted next to the procedure code.

ALL of the following

Related denial language referenced in policy: E4M - Not a covered service.

ALL of the following

Priority Health aligns with CMS and MDHHS diagnostic criteria for ambulance services and will follow those diagnostic criteria when applied.

ALL of the following

Authorization does not guarantee payment; proper documentation and coding remain required for payment decisions.

ALL of the following

Any claim with a submitted diagnosis code description that includes the word 'unspecified' is not payable.

ALL of the following

A long list of origin/destination modifiers that are not payable is provided in the policy and claims using those modifiers will be denied.

ALL of the following

Ambulance services should be coded with POS 41 or 42 and coverage will be considered when services are furnished in the appropriate setting; authorization may be required.

ALL of the following

Reimbursement may be adjusted for rural/super rural pickups and TN modifier is required in addition to origin/destination modifiers.

ALL of the following

Priority Health may deny or recoup payment if guidelines are not followed even if authorization had been obtained.

ALL of the following

See policy for the full list of origin/destination modifiers that are not payable for transportation.

ALL of the following

Bill A0888 for non-covered ambulance mileage beyond the closest appropriate facility.

ALL of the following

When authorization is required and not obtained in advance for fixed-wing or certain non-emergent transports, the claim will not be payable.

ALL of the following

Documentation must support the level of service billed and demonstrate medical necessity per CMS/MDHHS guidance.

ALL of the following

Ambulance stabilization non-transport: do NOT include an origin/destination modifier when billing.

ALL of the following

Denial triggers include missing authorization (when required), missing codes/modifiers, use of disallowed modifiers, and unspecified diagnosis descriptions.

ALL of the following

Authorization requirements and coding rules are subject to Priority Health review and payment integrity processes; follow policy details for claims submission.

ALL of the following

Use POS 41 or POS 42 on ambulance claims as appropriate for land or air/water transports.

ALL of the following

TN modifier must be reported in addition to origin/destination modifiers for rural/superrural transports; reimbursement may be adjusted based on pickup ZIP code.

ALL of the following

Policy references denial language/code E4M for not a covered service.

ALL of the following

Any claim with a diagnosis description that includes 'unspecified' will be not payable.

ALL of the following

Priority Health will follow CMS and MDHHS diagnostic criteria and requires proper authorization, coding, and documentation for payment of ambulance services.

ALL of the following

When authorization is required and missing, payment will be denied; authorization does not guarantee payment if documentation/coding requirements are not met.

ALL of the following

A provided long list of origin/destination modifiers are designated not payable for transportation; claims using them will be denied.

Billing instruction for excess mileage

Payment allowed only when level of care provided justifies ambulance transport; no payment if individual could have been safely transported by another means.

Diagnostic alignmentPriority Health follows CMS and MDHHS diagnostic criteria to determine medical necessity.

Authorization impactEmergent transport payable when correctly authorized (if required) and proper origin/destination modifiers submitted.

Non-transport stabilizationFor ambulance stabilization non-transport do NOT include an origin/destination modifier.

Prior Authorization

Authorization Exceptions and Requirements

Authorization is not required for emergency ground and helicopter ambulance services, and is not required for ambulance stabilization non‑transport for Priority Health Medicare Advantage members. Note that authorization may be required for non‑emergent transports and payment will not be allowed when authorization was required but not obtained in advance.

No authorization required: emergency ground and helicopter services
No authorization required: ambulance stabilization non‑transport for Priority Health Medicare Advantage members
Authorization may be required for non‑emergent transports; lack of required prior authorization can result in denied payment

Authorization noteCoverage will be considered for services furnished in the appropriate setting; authorization may be required.

Ambulance - Air or Water

POS 42Ambulance - Air or Water (use POS 42 for air or water ambulance services)

Coding guidanceAmbulance services should be coded with POS 42 when furnished by air or water in the setting appropriate to the patient's needs.

Rural considerationsRural/super rural reimbursement rules (TN modifier) and pickup ZIP code adjustments still apply to POS 42 transports when relevant.

Stabilization non-transport (do not include modifier)

Stabilization non-transportAmbulance stabilization is an on-scene response where the patient is treated and stabilized but not transported; report A0998 for response and treatment with no transport.

Modifier instructionDo NOT append an origin/destination modifier to stabilization non-transport claims.

CoverageNon-transport stabilization services are covered for Commercial, Medicare and Medicaid members.