CurrentProvidence Health PlanPolicy 118

Ambulance Transport

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Defines medical necessity, coverage, and billing expectations for emergent and non-emergent ground and air ambulance transport for Providence Health Plan members across applicable product lines.

Policy Summary

PayerProvidence Health Plan

PolicyAmbulance Transport

Policy CodePolicy 118

Change TypeNo material changes

Effective DateJul 1, 2026

Last ReviewJul 1, 2026

Next Review DateMar 1, 2027

Key ActionFor non-emergent ambulance requests, submit detailed documentation (run sheets, physician certification, medical history, treatments, loaded miles and rationale) to support medical necessity.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Not requiredPrior auth for emergent transports

Air & groundTransport modalities covered

A-E requiredNon-emergent air criteria

Multiple listedNon-covered situations

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CurrentProvidence Health PlanPolicy 118

Ambulance Transport

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Sign up for Providence Health Plan Policy 118 alerts

Get alerted when Policy 118 changes without checking for updates manually.

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Defines medical necessity, coverage, and billing expectations for emergent and non-emergent ground and air ambulance transport for Providence Health Plan members across applicable product lines.

Policy Summary

PayerProvidence Health Plan

PolicyAmbulance Transport

Policy CodePolicy 118

Change TypeNo material changes

Effective DateJul 1, 2026

Last ReviewJul 1, 2026

Next Review DateMar 1, 2027

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Not requiredPrior auth for emergent transports

Air & groundTransport modalities covered

A-E requiredNon-emergent air criteria

Multiple listedNon-covered situations

A0430–A0433, A0425–A0429, A0225, A0998

Representative codes

Coverage Criteria for Ambulance Transport

Emergent/Urgent Ground Ambulance

Covered when ALL of the following are met

Emergent/Urgent Ground: Member requires transportation to the nearest facility capable of treating the medical or behavioral health condition and other modes of transportation would endanger the member's health (or the health of an unborn child for pregnant women).nearest facility; immediate danger

Examples include transport from the scene of an accident or acute event, unconsciousness or shock, respiratory or cardiac distress, symptoms of possible stroke, severe hemorrhaging. Transport to a physician's office (destination modifier 'P') is not considered emergent/urgent.

Non-Emergent/Non-Urgent Ground Ambulance

Considered medically necessary when ALL of the following (A-C) are met

Non-Emergent Ground: A. Member requires services not available at their current location warranting transfer; B. Member is stable but could be jeopardized using a lesser level of transport due to one of the following: (1) cardiac monitoring, IV medications, or oxygen required; (2) bed-confined before and after trip or unable to sit due to pain/debility/immobility; (3) member can be moved only by stretcher; (4) needs restraint or close observation; C. Transport is to an approved destination (acute care hospital/CAH, inpatient rehab or SNF, dialysis facility for ESRD, from SNF to nearest supplier of needed services including return, or from home to/from a site of treatment).A-C all required

Approved destinations listed in C; all three A–C must be met.

Emergent/Urgent Air Ambulance

May be medically necessary when ALL of the following are met

Emergent Air: A. Member requires transport to an acute care hospital; B. Destination is the nearest facility capable of treating the condition (exceptions may be considered if nearest facility is on divert, has no beds or accepting physician, or air ambulance cannot land); C. Immediate, rapid transport is for a life-threatening condition; D. Ground ambulance transport would endanger the member's health due to at least one of: (1) ground transport time would be 30–60 minutes or more to reach appropriate facility; (2) instability of ground transportation; (3) pickup inaccessible by ground; or (4) great distances/obstacles (e.g., heavy traffic, weather) preclude timely ground transport.A-D all required

Examples of life-threatening conditions and reasons ground transport is unsafe are provided under Medical Reasonableness.

Non-Emergent/Non-Urgent Air Ambulance

May be medically necessary when ALL of the following (A-E) are met

Non-Emergent Air: A. Member is already receiving care at an acute care hospital; B. Required therapeutic/diagnostic services are not available at the current facility; C. An ambulance vehicle capable of acute medical transport is required (e.g., oxygen, cardiac monitoring, IV medications); D. Destination is the nearest facility capable of treating the condition (exceptions may be considered at medical director discretion for select situations); E. Ground transport would pose a threat or be not reasonable/feasible due to: (1) instability of ground transport; or (2) great distances that preclude ground transfer (for example would require overnight lodging/meals for ambulance staff).A-E all required

All five criteria A–E must be met; exceptions to nearest-facility requirement may be considered by medical director.

Ambulance Services for the Deceased

Ground for Deceased: Covered when either: (A) Member pronounced dead while en route or upon arrival at hospital/final destination (coverage limited to the medically necessary level of service provided), OR (B) Member pronounced dead after ambulance call made and ambulance dispatched but prior to pick-up and loading (coverage limited to BLS base rate only; no mileage or rural adjustment).one of A or B

Pronouncement of death must be made by an individual authorized under state law.

Air for Deceased: Air ambulance for deceased members may be considered medically necessary when: (A) The air transport would have otherwise met the air ambulance criteria; AND (B) one of: (1) Member pronounced dead after take-off but before being loaded (coverage limited to air base rate only; no mileage or rural adjustment), or (2) Member pronounced dead after being loaded but prior to or upon arrival (coverage unaffected).A and one of B conditions

Coverage differs by timing of pronouncement relative to dispatch, take-off, loading, and arrival.

Air ambulance covered criteria

Air ambulance is covered only when ALL of the following apply:

Air ambulance coverage conditions: 1) Transport is for a life-threatening medical emergency or an elective transfer for a higher level of care justified by clinical need; 2) Ground ambulance is unavailable or would cause an unreasonable risk of harm because of increased travel time; 3) Destination is the nearest facility capable of providing necessary care unless specialized services or higher-level trauma care are only available at a more distant facility; 4) Vehicle and crew meet required equipment/staffing and applicable state/local licensing/certification.all conditions must apply

Policy review considerations and medical reasonableness examples inform assessment (e.g., intracranial bleeding, cardiogenic shock, multiple severe injuries, transplant, neonatal emergencies).

The policy lists several non-covered / not medically necessary transport situations. These include transport from a location that is capable of treating the member's condition; transport to/from locations when the member is physically and mentally capable of riding as a passenger in a private vehicle; roundtrip residence-to-provider travel for routine appointments (unless specifically covered, e.g., dialysis); transports performed primarily for the convenience of the member, family, physician, or provider; air ambulance transport to non-acute care destinations absent Plan review/approval; use of non-ambulance modes of transport (private vehicle, commercial airline, taxi, rideshare, public transit, etc.); transports for services that are not covered; transport of ambulance staff without a patient onboard; and ambulance services when the origin or destination are not covered locations.

Air ambulance is limited to life‑threatening emergencies or transfers justified by clinical need when ground ambulance is unavailable or would pose an unreasonable risk of harm from increased travel time. The Plan explicitly states that air ambulance transportation for non‑emergency situations is not covered unless the exception for unavailable or dangerous ground transport applies; air transport solely for personal comfort or convenience is not covered.

When no transport occurs, do not report ground/air transport HCPCS codes (for example, A0428/A0429). Instead use a non‑transport HCPCS code such as A0998. Inclusion of a code in the policy does not guarantee coverage. All services and unlisted codes are subject to review for medical necessity, correct coding, and pricing; unlisted codes for potentially covered services are recommended to have prior authorization to avoid post‑service denial.

Examples of explicit non‑covered conditions include transports from locations capable of treating the condition; transports when the member is able to ride as a passenger in a private vehicle; roundtrip residence‑to‑provider transports for routine appointments (unless specifically covered); transports performed mainly for convenience; air ambulance to non‑acute care destinations without Plan approval; non‑ambulance modes of transport (commercial airline, taxi, rideshare, public transit, private vehicles); transport of staff without a patient; and ground services when the patient died before transport and before dispatch.

Additional examples of non‑coverage include situations where a commercial flight or other non‑ambulance means could safely accomplish the transport, or where transport is to a facility that is not the nearest appropriate facility without justification. The policy reiterates that ambulance transportation solely for personal comfort or convenience is not covered, and that incorrect origin/destination modifier combinations may indicate transports unlikely to meet coverage criteria.

Coding and Mileage Reporting

Referenced HCPCS CodesHCPCS

A0427	Ambulance service, advanced life support, emergency transport, level 2 (example emergency transport HCPCS referenced)
A0429	Ambulance service, ground, advanced life support, non-emergency transport / emergency transport (example emergency transport HCPCS referenced)
A0426	Ambulance service, basic life support, non-emergency transport (example non-emergency HCPCS referenced)
A0428	Ambulance service, basic life support, emergency/non-emergency (example non-emergency HCPCS referenced)
A0430	Air ambulance service, fixed wing, transport (referenced for emergent and non-emergent air transport)
A0431	Air ambulance service, rotary wing, transport (referenced for emergent and non-emergent air transport)

Representative ambulance HCPCS/CPT codes mentionedHCPCS

A0430	Fixed wing air transport
A0431	Rotary wing air transport
A0425	Emergency transportation: Ambulance service- neonatal transport
A0427	Ambulance service, Advanced Life Support (ALS), emergency transport, Level 1
A0428	Ambulance service, Basic Life Support (BLS), non-emergency transport
A0429	Emergency transportation: Ambulance service- Basic Life Support (BLS)
A0433	Ambulance service - Advanced Life Support (ALS), level 2
A0225	Ground ambulance transport and mileage codes (listed in document)
A0425	Ground mileage, per statute mile (as referenced)
A0998	Ambulance response and treatment, no transport

Ground transport time threshold for air necessity

ThresholdGround transport would take 30–60 minutes or more to reach an appropriate facility

ContextApplied when ground transport time poses a threat to the member's health and immediate, rapid transport is required for a life‑threatening condition

Applies toEmergent/urgent air ambulance consideration (HCPCS A0430/A0431) as one of criteria D.1 in air ambulance coverage

Loaded miles reporting

Required documentationNumber of loaded miles (miles traveled when the patient was in the ambulance) must be documented

Where to recordInclude loaded miles on ambulance run sheets and itemized charges submitted with the claim/request

Provider Actions, Prior Authorization & Documentation

Prior Authorization

Prior authorization not required for urgent/emergent transports; non-emergent may require PA

Prior authorization is not required for urgent/emergent ambulance transports, including air ambulance; non-emergent transports may require review/authorization per plan benefits. Emergent/urgent transports may still be reviewed post-service for medical necessity.

Do not submit PA for clearly urgent/emergent transports (ground or air).
For non-emergent transports, check member benefits and obtain PA when the plan requires it.

Prior Authorization

HCPCS codes may not routinely require PA; unlisted/potentially covered services should be reviewed

HCPCS ambulance codes may not routinely require prior authorization, but unlisted codes (and services that are only potentially covered) should be reviewed or have PA to avoid post-service denial; coverage criteria apply regardless of the HCPCS code used.

If submitting an unlisted code (e.g., A0998) or other potentially covered service, consider obtaining prior authorization.

Background

Ambulance transport services are categorized as emergent/urgent or non‑emergent/non‑urgent for both ground and air. Emergent or urgent transports are provided when other modes of transportation would endanger the member's health and immediate transport to the nearest facility capable of treating the condition is required (examples include unconsciousness, shock, respiratory or cardiac distress, or suspected stroke). Non‑emergent transports are for clinically stable members who nonetheless require ambulance‑level services (for example, stretcher‑only movement, need for cardiac monitoring/IV/oxygen, or bed‑confined status) and who are being moved to an appropriate approved destination.

Definitions

Emergent/Urgent transport — definition and triggers

DefinitionTransport required when other modes of transportation would endanger the member's health or when immediate transportation to the nearest capable facility is necessary

Examples/TriggersScene of an accident, unconsciousness, shock, respiratory or cardiac distress, symptoms of possible stroke, severe hemorrhage

Coding noteEmergent/urgent ground examples reference HCPCS A0427, A0429; destination modifier 'P' (physician's office) is not emergent/urgent

Non-emergent transport — definition for stable members requiring ambulance-level services

DefinitionTransport for stable members who nonetheless require ambulance‑level services (e.g., cardiac monitoring, IV/oxygen, stretcher‑only movement, bed‑confined) and are being moved to an approved destination

Stability requirement

Policy Summary

PayerProvidence Health Plan

PolicyAmbulance Transport

Policy CodePolicy 118

Change TypeNo material changes

Effective DateJul 1, 2026

Last ReviewJul 1, 2026

Next Review DateMar 1, 2027

SourceLink

On This Page

Use for reviewLoaded miles are part of recommended documentation to support medical necessity and mileage charges

Coverage and medical necessity rules are applied during review even if a specific HCPCS code does not routinely require PA.

Step Therapy

No step therapy specified

No step therapy is specified in this policy for ambulance transport services.

Note

Obtain review/PA for unlisted or exceptional services

If using unlisted, unusual, or exceptional service codes or submitting transports that are borderline, obtain prior authorization and include full supporting documentation to reduce risk of denial on review.

Unlisted codes are reviewed at claim level for medical necessity and correct coding.
Prior authorization is recommended for potentially covered but unlisted services to avoid post-service denial.

Documentation Required

Documentation must support unique clinical circumstances; physician order alone insufficient

Documentation must demonstrate the unique clinical circumstances that justify non-emergent ambulance use; the presence of a physician order alone does not establish medical necessity.

Coverage decisions for non-emergent transports are made case-by-case at medical director discretion.

Documentation Required

Include run sheets, PCS, charges, mileage and detailed clinical information

Submit complete ambulance records and clinical detail with requests or claims to support medical necessity and to avoid delays or denials.

Run sheets and Physician Certification Statements (PCS).
Procedures/supplies used, base charge, mileage (number of loaded miles) and itemized charges.
Detailed medical information: objective signs/symptoms, history, mobility/functional/mental status, on-scene assessment, treatments and responses.
Point of pick-up and destination names/addresses and, for hospital transfers, reason patient could not be treated at current hospital.

Denial Risk

Post-service review may deny emergent transports lacking supporting documentation

Urgent/emergent transports may be subject to post-service review; if documentation does not support medical necessity, the claim may be denied even when transport was emergent.

Keep complete run sheets and clinical records available for post-service medical necessity review.

Denial Risk

Incorrect origin/destination modifiers may trigger denials

Claims with incorrect or implausible origin/destination modifier combinations (for example, 'S' as a destination or 'X' in an origin position) or other improper modifier use are not likely to meet medical policy criteria and may deny.

Report each leg of transport as a separate line with appropriate origin & destination modifiers.
Verify modifiers: 'S' (scene) should not be used as a destination; 'X' is a destination-only modifier.

Denial Risk

Unlisted codes can be denied if service is non-covered; seek PA for potentially covered unlisted codes

Unlisted HCPCS codes submitted for services that are non-covered under this policy will be denied as not covered; for unlisted codes representing potentially covered services, prior authorization is recommended to avoid post-service denial.

All unlisted codes are reviewed for medical necessity, correct coding, and pricing at the claim level.
If an unlisted code is used for a potentially covered service, obtain PA when appropriate.

Member is clinically stable but would be jeopardized using a lesser level of transport due to listed conditions (cardiac monitoring, bed‑confined, stretcher only, need for restraint/close observation)

Approved destinationsAcute care hospital/CAH, inpatient rehab, skilled nursing facility, dialysis for ESRD, transfers from SNF to nearest supplier, or home to/from treatment site (includes physician's office)

Bed-confined — definition criteria

DefinitionAn individual is 'bed‑confined' if they: (1) are unable to get up from bed without assistance; (2) are unable to ambulate; and (3) are unable to sit in a chair or wheelchair

Scope'Bed‑confined' is not synonymous with 'bed rest' or 'nonambulatory' and alone is neither sufficient nor necessary to determine ambulance coverage

Use in criteriaBed‑confined status may be considered as one element when reviewing whether ambulance transport is medically necessary

Emergency medical condition — definition per prudent layperson standard

DefinitionAn 'emergency medical condition' is one that a prudent layperson would reasonably expect, if not treated immediately, to result in serious impairment of bodily function, serious dysfunction of any bodily organ or part, or place health in serious jeopardy (including the health of an unborn child)

IncludesBehavioral health crises and acute symptoms of sufficient severity such as severe pain

Practical implicationDetermines urgent/emergent transport eligibility and may trigger non‑PA urgent/emergent handling; see Policy Guidelines for related definitions

Appropriate facilities — definition and when transport to a more distant facility may be appropriate

Definition'Appropriate facilities' are institutions generally equipped to provide the needed hospital or skilled nursing care and have available physicians or specialists to treat the patient's condition

Distance exceptionA more distant facility is not appropriate solely to access a specific physician; a more distant facility may be appropriate if specialized services or a higher level of trauma care are only available there

Operational considerationsNearest facility may be bypassed for reasons such as divert status, no available beds/accepting physician, or inability of air ambulance to land—exceptions considered case‑by‑case