CurrentTexas Children's Health PlanPolicy 6189

Non-emergency Ambulance Transportation Guideline

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This guideline governs Texas Children's Health Plan authorization and medical-necessity review for non-emergency ambulance transportation for Medicaid members, including provider submission, documentation, timing, coding, coverage, and denial requirements.

Policy Summary

PayerTexas Children's Health Plan

PolicyNon-emergency Ambulance Transportation Guideline

Policy CodePolicy 6189

Change TypeNo material clinical or coverage changes

Effective DateMar 22, 2024

Next Review DateN/A

Key ActionSubmit recurring or multi-day transportation requests seven days before scheduled transport.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

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CurrentTexas Children's Health PlanPolicy 6189

Non-emergency Ambulance Transportation Guideline

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Policy Summary

PayerTexas Children's Health Plan

PolicyNon-emergency Ambulance Transportation Guideline

Policy CodePolicy 6189

Change TypeNo material clinical or coverage changes

Effective DateMar 22, 2024

Next Review DateN/A

Key ActionSubmit recurring or multi-day transportation requests seven days before scheduled transport.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Advance submission for recurring or multi-day requests

1/monthUnscheduled trips permitted when none are requested

3Air ambulance qualifying conditions

Not coveredHome-to-PPECC transport

Medical Necessity and Coverage Requirements

General medical-necessity criteria

Non-emergency ambulance transport is eligible when medical necessity is established and the requested service is supported by the required documentation.

General non-emergency transport

Medical condition requiring ambulance transport: At least one condition contraindicates transport by other means.

Air ambulance criteria

Air ambulance transport may be covered when all applicable authorization requirements are met and at least one of the following conditions exists.

Air ambulance qualifying conditions: The member's condition requires immediate and rapid ambulance transportation that standard automotive ground ambulance could not provide; the pickup point is inaccessible by standard automotive ground vehicle; or great distances or other obstacles require transport to the nearest appropriate facility.

Air transport codes must be submitted with the corresponding air mileage code.

Behavioral health facility transfer

Behavioral health facility transportation may be approved when the clinical transfer requirements are supported.

Inpatient behavioral health facility transfer: Clinical documentation supports that transfer is pending facility acceptance and bed availability.

Requests not meeting medical necessity or involving an out-of-network facility require Medical Director review.

High-acuity recurring transport

Certain higher-acuity members may receive authorization for all requested trips when the underlying trip purpose meets this guideline.

High-acuity recurring transport: The member receives home skilled nursing or Private Duty Nursing services, or has a tracheostomy with ventilator dependence; and the purpose of each trip meets the non-emergency ambulance medical-necessity requirements.

This provision permits approval for all requested trips; it does not remove the underlying medical-necessity requirement.

Transportation during a hospital stay is not covered. An exception applies to a one-time transport immediately after discharge to the member’s home. Providers should document the member’s inpatient status and identify any qualifying post-discharge home transport.

Non-emergency ambulance transportation between a member’s home and a Prescribed Pediatric Extended Care Center (PPECC) is not covered. Transportation to and from a PPECC is included in the PPECC benefit.

Preauthorization does not guarantee benefits or eligibility. It establishes only that the requested treatment or service meets medical-necessity requirements. All services remain subject to applicable benefit limitations and exclusions.

Transportation requested primarily for the convenience of the member, the member’s family, or the physician, or to obtain a service considered not medically necessary, is referred to a Medical Director or Physician Reviewer and follows the Denial Policy.

A nonemergent transfer to an out-of-network facility is subject to Medical Director or Physician Reviewer review under the Denial Policy. Approval requires clinical support for medical necessity and compliance with the applicable review requirements.

Billing Codes and Unit Rules

Ground ambulance and supply codesHCPCSCovered

A0425	Mileage; 1 unit = 1 mile
A0426	ALS (Advanced life support) truck; 1 unit for each trip
A0428	BLS (Basic life support) truck; 1 unit for each trip
A0422	Supplies for oxygen administration; 1 unit for each trip
A0382	BLS disposable supplies; 1 unit for each trip
A0398	ALS disposable supplies; 1 unit for each trip

Air ambulance and specialized vehicle codesHCPCSCovered

A0430	Air ambulance transport, fixed wing
A0431	Air ambulance transport, rotary wing
A0435	Air mileage, fixed wing
A0436	Air mileage, rotary wing
A0999	Unlisted ambulance service; used for specialized emergency medical services vehicles such as boat or airboat

Round-trip units

Round-trip billingMultiply units by 2 when the service is round trip.

Unit adjustmentUse twice the applicable units for a round-trip service.

Applicable serviceThe round-trip unit adjustment applies when the authorized transportation includes both the outbound and return portions of the trip.

Ground mileage

CodeA0425 — mileage.

Unit definition1 unit = 1 mile.

Billing requirement

Authorization, Documentation, and Denial Risks

Prior Authorization

Submit Through Utilization Management

Submit prior-authorization requests for non-emergency ambulance transport to the Utilization Management Department. Requests are accepted by fax, mail, or electronically and are processed during normal business hours.

Prior Authorization

Request Must Come From the Provider

The prior-authorization request must originate from the member’s physician, nursing facility, healthcare provider, or other responsible party. TCHP does not accept non-emergency transportation authorization requests directly from ambulance or medical transportation vendors.

Prior Authorization

Meet Submission Deadlines

Submit requests within the required advance timeframes. A one-day request may be submitted the day before transport; if that is not feasible, it may be submitted on the next business day after transport. Recurring requests and requests for more than one day must be submitted at least 7 days before the scheduled transport.

Policy Context

Non-emergency ambulance transportation is intended for Medicaid members whose medical condition makes ordinary transportation unsafe or medically inappropriate. Depending on the member’s needs, ambulance transport may support monitoring, airway or ventilator management, controlled positioning, oxygen assistance, isolation, or personnel capable of managing behavioral or clinical risks during transport.

Key Transportation Terms

Non-emergency transport

Scheduled medical appointmentTransport to or from a scheduled medical appointment.

Licensed treatment facilityTransport to or from a licensed facility for treatment.

Post-discharge transportTransport to the member’s home after discharge from a hospital.

Medical requirementThe member must have a medical condition such that ambulance use is medically required, such as bed confinement or when alternate transportation may endanger the member’s health.

Ambulance transport

Advanced life supportALS ambulance services.

Basic life support

Policy Summary

PayerTexas Children's Health Plan

PolicyNon-emergency Ambulance Transportation Guideline

Policy CodePolicy 6189

Change TypeNo material clinical or coverage changes

Effective DateMar 22, 2024

Next Review DateN/A

Key ActionSubmit recurring or multi-day transportation requests seven days before scheduled transport.

SourceLink

On This Page

A0425 must be submitted with a qualifying ground ambulance transport code.

Ground transport units

A0426ALS (Advanced life support) truck — 1 unit for each trip.

A0428BLS (Basic life support) truck — 1 unit for each trip.

Shared unit ruleBill 1 unit for each ground transport trip under A0426 or A0428.

Oxygen and disposable supply units

A0422Supplies for oxygen administration — 1 unit for each trip.

A0382BLS disposable supplies — 1 unit for each trip.

A0398ALS disposable supplies — 1 unit for each trip.

One-day request: submit the day before transport, or the next business day when advance submission is not feasible.
Recurring or multi-day request: submit 7 days before scheduled transport.

Documentation Required

Behavioral Health and Out-of-Network Review

Transportation to an inpatient behavioral health facility may be approved when clinical documentation supports that transfer is pending facility acceptance and bed availability. Requests that do not meet medical-necessity criteria or that seek transport to an out-of-network facility require Medical Director or Physician Reviewer escalation under the denial policy.

Include clinical documentation supporting the behavioral-health transfer and pending acceptance/bed availability.
Escalate medically unsupported or out-of-network requests for Medical Director/Physician Reviewer review.

Prior Authorization

Unscheduled Trip Allowance

For requests that meet approval criteria, TCHP may add up to one unscheduled trip per month when no unscheduled trips were requested, to support access to transportation. If unscheduled trips are included in the request, they may be approved when medically necessary.

Allowance: up to one unscheduled trip per month when none was requested.
Any requested unscheduled trip remains subject to medical necessity.

Note

Communicate Authorization Details

The requesting provider must give the transporting ambulance provider the prior authorization number (PAN) and the approved dates of service. The ambulance provider must use that PAN when submitting the claim.

Communicate the PAN to the transporting ambulance provider.
Communicate all approved service dates.

Unsupported block type: prior_auth

Prior Authorization

Pregnancy Transport Requires Authorization

Non-emergency ambulance transport for a pregnant member requires prior authorization. All non-emergency ambulance criteria must be met before the transport is authorized.

Documentation Required

Required Authorization Records

Maintain and submit the records supporting the request. The Nonemergency Ambulance Prior Authorization Request form must be signed and dated by a Medicaid-enrolled requesting provider, such as a physician, nursing agency, or other Medicaid provider.

Supporting documentation and physician’s orders.
Completed Nonemergency Ambulance Prior Authorization Request form.
Non-emergency Ambulance Exception form, when applicable.
The requesting provider must retain the supporting documentation and orders.

Documentation Required

Document Medical Necessity and Trip Details

Document the member’s physical condition establishing medical necessity and provide enough trip detail for Utilization Management to evaluate the request and the number of trips and miles requested.

Necessary equipment, treatment, or personnel required during transport.
Scheduled appointment dates, times, and locations.
Origination and destination points.
Method of transport.
Clinical condition supporting ambulance transport rather than another means.

Documentation Required

Document Inpatient Status

State whether the member is currently an inpatient in a hospital and provide documentation of that status. Transport during a hospital stay is not covered, except for one one-time transport immediately after discharge to the member’s home.

Document current inpatient status.
Document an immediate post-discharge transport to home when requesting the limited exception.

Denial Risk

Unsupported or Convenience Transport May Be Denied

Requests primarily for the convenience of the member, family, or physician, or for a service that is not medically necessary, will be referred to a Medical Director or Physician Reviewer and handled under the Denial Policy. Non-emergent transfer to an out-of-network facility is included in this denial-review process.

Support the request with clinical documentation of medical necessity.
Do not request ambulance transport solely for convenience.
Out-of-network facility transfers require reviewer escalation.

Denial Risk

Inpatient Transport Limitation

Transportation during a hospital stay is not covered. The only stated exception is a single transport immediately after discharge to the member’s home, which must be documented as such.

No covered transport during the inpatient stay.
One-time immediate post-discharge transport to home is the exception.

Billing Rule

Mileage Requires Ground Transport

Mileage code A0425 must be billed with a qualifying ground ambulance transport code. Billing A0425 without a qualifying ground transport code will result in denial.

A0425 represents mileage at 1 unit per mile.
Qualifying ground transport codes include A0426, A0428, A0433, A0434, and A0999; the source’s explicit denial rule identifies A0426, A0428, A0433, and A0434.

Denial Risk

BLS Supplies Require BLS Transport

BLS disposable supplies code A0382 will be denied unless a corresponding BLS transport is billed on the same claim.

A0382: BLS disposable supplies, 1 unit per trip.
Bill with the corresponding BLS transport on the same claim.

Denial Risk

ALS Supplies Require ALS Transport

ALS disposable supplies code A0398 will be denied unless a corresponding ALS transport is billed on the same claim.

A0398: ALS disposable supplies, 1 unit per trip.
Bill with the corresponding ALS transport on the same claim.

Denial Risk

PPECC Transportation Excluded

Non-emergency ambulance transportation between a member’s home and a Prescribed Pediatric Extended Care Center (PPECC) is not covered because transportation to and from the PPECC is included in the PPECC benefit.

Home-to-PPECC transport is excluded.
PPECC-to-home transport is excluded.

BLS ambulance services.

Wheelchair vanWheelchair van services.

Air ambulanceAir ambulance services.