Currentpriority healthPolicy N/A

AMBULANCE SERVICES

Defines Priority Health's coverage, coding, documentation, authorization, and payment rules for ambulance transport, air transport, and non-transport stabilization services affecting providers and ambulance suppliers serving Priority Health members.

Policy Summary

Payerpriority health

PolicyAMBULANCE SERVICES

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateMar 1, 2026

Key ActionObtain prior authorization for all fixed‑wing transports (emergent and non‑emergent).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Fixed‑wingAuthorizations required

A0998Stabilization code

Missing modifiersDenial trigger

A0425Key mileage code

Ambulance Coverage Criteria

Ambulance coverage and billing criteria — medical necessity, level of service, coding/modifiers, authorizations when required

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ALL of the following

Emergent transports to the nearest facility that can provide emergency care are covered for all plans.
Non-emergent transportation and medically necessary inter‑facility transfers are covered without prior authorization except where this policy explicitly requires prior authorization (e.g., fixed‑wing transports).
For Medicare beneficiaries, coverage requires documentation that other means of transportation are contraindicated and that the level of service billed is supported by clinical documentation (treatment provided during transport).

ALL of the following

Suppliers must document condition severity, pickup point, miles, dispatch record, and physician certification when required; bed confinement alone is not sufficient without meeting criteria.
Ambulance services are categorized by level of ground and air service (BLS, ALS1, ALS2, SCT, fixed‑wing/rotary wing) and the billed level must reflect medically necessary treatment during transport.

Coding, modifiers, and billing rules: claims must include appropriate procedure codes and required origin/destination modifiers; missing required modifiers will result in denials (exception QL for pronouncement after call). A0998 (ambulance response and treatment, no transport) must NOT include origin/destination modifiers.

ALL of the following

No payment is allowed if the individual could have been safely transported by another means, regardless of availability of that alternative transportation.
Mileage beyond the closest appropriate facility is not payable (use A0888 for non‑covered mileage).
Ambulance services included with an inpatient admission are generally not separately payable except limited day‑of‑admission/discharge exceptions.
Fixed‑wing and other non‑emergency services not authorized in advance when prior authorization is required are not payable.

ALL of the following

Prior authorization is required for fixed‑wing transports (both emergent and non‑emergent).
Authorization is NOT required for emergency ground and helicopter ambulance services and for ambulance stabilization non‑transport for Priority Health Medicare Advantage members.
For Medicare indications that do not meet NCD/LCD or specific medical policy, a Pre‑Service Organization Determination (PSOD) is required.

ALL of the following

ESRD‑related non‑emergency BLS transports to/from dialysis are subject to a payment reduction when modifier G (hospital‑based ESRD facility) or modifier J (freestanding ESRD facility) is appended; follow CMS methodology for payment reduction and report institution‑based ambulance appropriately (e.g., revenue code 0540 on facility claims).

ALL of the following

Priority Health aligns with CMS and MDHHS diagnostic criteria; claims with unspecified diagnosis descriptions or disallowed origin/destination modifier combinations are not payable.

ALL of the following

A0998 (ambulance response and treatment, no transport) is covered by Priority Health Medicare and should not include origin/destination modifiers; other ambulance services require correct origin/destination modifiers for payment when applicable.

ALL of the following

Suppliers must maintain detailed documentation (condition severity, pickup point, miles, dispatch record, physician certification when required) to support medical necessity and billed level of service.

ALL of the following

Claims missing required origin/destination modifiers will be denied (except QL pronouncement after call). Specific origin/destination modifier combinations listed as not payable will result in denial.

ALL of the following

For emergent transport, payment is allowed when correctly authorized if necessary and when the correct origin and destination modifier combination are submitted next to the procedure code.

ALL of the following

Ambulance stabilization, non‑transport (A0998) is covered by Priority Health Medicare; do NOT include origin/destination modifiers on A0998 claims.

ALL of the following

Ground mileage should be billed using appropriate HCPCS mileage codes (e.g., A0425); non‑covered mileage (beyond closest appropriate facility) should be billed with A0888 and is not payable.

ALL of the following

Providers must request prior authorization where required (fixed‑wing) and obtain PSODs for Medicare situations that do not meet NCD/LCD or specific medical policy.

ALL of the following

Payment for medically necessary ambulance services is based on the level of care provided; no payment if patient could have been safely transported by other means.

ALL of the following

Certain origin/destination modifier combinations and unspecified diagnosis descriptions are listed as not payable; submit correct procedure codes and modifiers to avoid denial.

ALL of the following

Non‑emergent inter‑facility transfers are covered without prior authorization unless policy requires authorization (fixed‑wing); emergency ground and helicopter transports are exempt from prior authorization requirements.

ALL of the following

See coding sections for HCPCS codes for ground, air, and stabilization/non‑transport (e.g., A0425, A0430, A0998) and ESRD modifier guidance (G/J).

ALL of the following

When denial is based on missing modifiers or lack of medical necessity documentation, providers may appeal with supporting documentation showing condition required ambulance transport and correct origin/destination modifiers.

ALL of the following

This coverage and billing criteria apply to Priority Health members and align with CMS and MDHHS guidance where indicated; state‑specific rules (e.g., NC) may apply as documented elsewhere in the policy.

ALL of the following

A0998 does not require origin/destination modifiers; do not append them to ambulance stabilization, non‑transport charges.

ALL of the following

Ensure origin/destination modifiers are submitted next to the procedure code for emergent transports to be payable when required; missing modifiers are a common billing trigger for denial.

ALL of the following

Priority Health Medicare covers A0998 (ambulance response and treatment, no transport) while Original Medicare may not; adherence to documentation and modifier rules remains required.

ALL of the following

Payment will be made only when all applicable coverage criteria, documentation, coding, modifier, and authorization requirements are met.

ALL of the following

Use appropriate HCPCS codes for ground (e.g., A0425), air (e.g., A0430/A0431), and stabilization (A0998); apply ESRD modifiers G or J where applicable for payment reduction as described by CMS methodology.

ALL of the following

Emergency ground and helicopter services are exempt from prior authorization requirements; fixed‑wing transports still require authorization even if emergent.

ALL of the following

Claims with missing required origin/destination modifiers or with prohibited modifier combinations will be denied; verify modifiers before submission.

ALL of the following

When Medicare indications do not meet NCD/LCD/specific medical policy, obtain a Pre‑Service Organization Determination (PSOD) before providing transport to ensure coverage consideration.

ALL of the following

When prior authorization is required and obtained, ensure authorization details and supporting documentation accompany claims to avoid denials.

ALL of the following

Follow Priority Health authorization processes for fixed‑wing transports and other services requiring prior authorization as described in the provider portal or authorization guidance.

ALL of the following

Exception QL applies for pronouncement after call (affects origin/destination modifier denial handling).

ALL of the following

Coverage is conditioned on medical necessity, correct level of service documentation, appropriate coding and modifiers, and prior authorization when required (fixed‑wing).

End of criteria set.

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)
A0888	Non-covered ambulance mileage, per mile (e.g., for miles traveled beyond closest appropriate facility)

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)
A0431	Ambulance service, conventional air services, transport, one way (rotary wing)

OpenPayer

AMBULANCE SERVICES

Ambulance Coverage Criteria

Billing Codes and Modifiers

Authorization, Documentation, and Provider Responsibilities

Key Definitions