DraftUnitedHealthcarePolicy BIP005.P

Ambulance Transportation

Defines UnitedHealthcare West's interpretation of benefits and regulatory context for ambulance and air ambulance transportation services affecting enrollees in scope of the West Benefit Interpretation Policy.

Policy Summary

PayerUnitedHealthcare

PolicyAmbulance Transportation

Policy CodePolicy BIP005.P

Change TypeMaterial additions and revisions

Effective DateAug 1, 2025

Next Review DateN/A

Key ActionEnsure enrollees pay no more than the in‑network cost‑sharing amount for services from noncontracting ambulance providers and reimburse providers for the difference as required.

SourceLink

POLICY UPDATE CHANGES

Requires enrollees/insureds receiving covered services from noncontracting ground ambulance providers to pay no more than the in‑network cost‑sharing amount and prohibits providers from charging more.

Prohibits noncontracting ground ambulance providers and assignees from reporting to credit agencies, initiating civil action, using wage garnishment or liens on primary residences for at least 12 months after initial billing.

Mandates annual publication of allowable maximum county ambulance rates by the designated authority and submission of reports to Department of Insurance, DMHC, and Office of Health Care Affordability.

Revised language pertaining to Assembly Bill No. 651 Chapter 537, Section 76000.10 and California Health and Safety Code Section 1797.233; added and updated reference links to multiple California Health and Safety Code sections.

CA citationsstate regulations referenced

Ambulance and Air Ambulance Coverage Rules

California emergency ambulance and air ambulance coverage provisions

Statutory coverage protections and cost-sharing rules for emergency and air ambulance services (California):

ALL of the following

Determination that the enrollee reasonably believed the condition was an emergency shall not be based solely on retrospective analysis of level of care or final discharge.
Plan is not required to pay if services were never performed, an emergency condition did not exist, or there are findings of fraud, incorrect billing, services not covered under member's benefit plan, or invalid membership for the claim.

ALL of the following

At the time the plan pays the noncontracting provider, the plan shall inform the enrollee and the noncontracting provider of the in-network cost-sharing amount owed by the enrollee.
Any cost sharing paid by the enrollee for services subject to this section shall count toward the limit on annual out-of-pocket expenses and toward any deductible in the same manner as if attributed to a contracting provider.
A noncontracting provider may advance to collections only the in-network cost-sharing amount the enrollee failed to pay; providers remain subject to Medi-Cal balance billing protections for Medi-Cal beneficiaries.

Statutory provisions and programs related to emergency medical air transportation (including creation/use of Emergency Medical Air Transportation Fund and related reimbursement augmentation) apply as described in California law.

Coverage and collection criteria for noncontracting ground ambulance services

Rules that govern cost sharing, counting toward OOP limits/deductibles, and provider collection rights for noncontracting ground ambulance services.

An enrollee/insured who receives covered services from a noncontracting ground ambulance provider shall pay no more than the in-network cost-sharing amount (the amount the enrollee/insured would pay for the same covered services from a contracting provider).

At the time of payment by the plan/insurer to the noncontracting provider, the plan/insurer shall inform the enrollee/insured and the noncontracting provider of the in-network cost-sharing amount owed and shall disclose whether the enrollee's/insured's coverage is regulated by the department or not state-regulated.

Any in-network cost-sharing amount paid by the enrollee/insured shall count toward the limit on annual out-of-pocket expenses and shall count toward any deductible in the same manner as cost sharing attributed to a contracting provider.

The plan/insurer shall reimburse the noncontracting provider for the difference between the in-network cost-sharing amount and the applicable allowed payment basis (e.g., a local government rate if established; otherwise specified state/regulatory rate or reasonable & customary value), unless otherwise agreed.

Ambulance coverage criteria

Coverage and limitations for ambulance services (ground and air) and treatment of noncontracting air ambulance providers under California law.

Ground ambulance transportation is covered when medically necessary for specified transfers and emergency transports; covered transfers include inter-hospital or skilled nursing facility transfers (skilled care only), hospital and renal dialysis facility, skilled nursing facility and dialysis facility (skilled care only), skilled nursing facility and radiation therapy (skilled care only), skilled nursing facility and hospital, and to the member's home.

ALL of the following

The member's destination is an acute care hospital.
The member's condition is such that ground ambulance would endanger the member's life or health.
Inaccessibility to ground ambulance transport or an extended length of time required to transport by ground could endanger the member.

Coding and Payment Basis

No specific codes listed in this partmixed

No codes listed

Allowed payment basis for insurer/plan reimbursementsmixed

local government rate	If there is a rate established or approved by the local government, the rate established or approved by the governing body of the local government having jurisdiction for that area or subarea (including an exclusive operating area pursuant to Section 1797.85).
state/regulatory rate	If the local government does not have an established or approved rate, the amount established by Section 1300.71(a)(3)(B) of Title 28 of the California Code of Regulations (or other specified state/regulatory rate).
reasonable and customary value	If no local rate exists, the reasonable and customary value for the services rendered, based on statistically credible information updated at least annually that considers provider training, qualifications, nature of services, usual fees, prevailing regional rates, practice economics, and any unusual circumstances.

inv-06: In-network cost-sharing cap for noncontracting air ambulance

In-network cost-sharing capEnrollee pays no more than the in‑network cost‑sharing amount for services from a noncontracting air ambulance provider; the plan must inform the enrollee and provider of that amount at time of payment.

OOP & deductible creditAny cost sharing paid under this provision counts toward the enrollee's annual out‑of‑pocket limit and toward deductibles as if attributed to a contracting provider.

Collection limitA noncontracting provider may advance to collections only the in‑network cost‑sharing amount that the enrollee failed to pay.

Payment dispute remediesA health care service plan or provider may seek relief in court or use existing dispute resolution processes to resolve payment disputes.

inv-07: Report frequency

Provider Billing, Notification, and Authorization Requirements

Prior Authorization

911 Emergency Ambulance Transport — No Prior Authorization or Payment Refusal

No health care service plan shall require prior authorization or refuse to pay for ambulance or ambulance transport services provided as the result of a 911 emergency response when either: (1) the request was made for an emergency medical condition and ambulance transport services were required, or (2) the enrollee reasonably believed the condition was an emergency requiring ambulance transport. The plan may still deny payment if services were never performed, an emergency condition did not exist, or there are findings of fraud, incorrect billings, services not covered under the member's benefit plan, or invalid membership at the time services were delivered.

Applies to ambulance transport requested via 911 emergency response
Plans may not retroactively base the determination solely on level of care or final discharge

Billing Rule

Payment and Notification Obligations for Plans/Insurers

Key Terms and Definitions

inv-11: Emergency health care services

DefinitionEmergency health care services includes ambulance and ambulance transport services and out‑of‑area coverage; basic health care services includes ambulance and ambulance transport services provided through the '911' emergency response system.

ScopeCovers both ground and air ambulance transport as part of emergency health care services.

Availability implicationDesignated emergency health care services are expected to be available 24/7 to access nearest 24‑hour emergency facility as referenced elsewhere in the policy.

inv-12: Rotary wing / Fixed wing

Rotary wingRotary wing means a helicopter that generates lift through rotor blades that revolve around a mast.

Fixed wing

Policy Summary

PayerUnitedHealthcare

PolicyAmbulance Transportation

Policy CodePolicy BIP005.P

Change TypeMaterial additions and revisions

Effective DateAug 1, 2025

Next Review DateN/A

Key ActionEnsure enrollees pay no more than the in‑network cost‑sharing amount for services from noncontracting ambulance providers and reimburse providers for the difference as required.

SourceLink

On This Page

A noncontracting ground ambulance provider may only advance to collections the in-network cost-sharing amount that the enrollee/insured failed to pay. For a minimum of 12 months after initial billing, a noncontracting provider or assignee shall not report adverse information to credit reporting agencies or commence civil action against the enrollee/insured (includes restrictions on wage garnishment and liens on primary residences).

Use of an ambulance (land or air) is covered without prior authorization when the member reasonably believes there is an emergency medical or psychiatric condition requiring ambulance transport to access emergency health care services. Non-emergency ambulance use is covered only when authorized by the member's network medical group or UnitedHealthcare or when documentation demonstrates medical necessity.

When a member receives covered services from a noncontracting air ambulance provider, the member shall pay no more than the in-network cost-sharing amount; the insurer shall inform the member and the noncontracting provider of that amount at the time the insurer pays the provider. Any cost sharing counts toward annual out-of-pocket limits and deductibles as if attributed to a contracting provider.

Excluded services include routine transport when other means would not endanger health, transports when unable to locate other transport and health not compromised, convenience transports, wheelchair/taxi services, transport to coroner/mortuary, personal transportation costs, inter-facility transfers for convenience, and certain out-of-country return transports when foreign facility can manage the condition.

Report frequencyAnnually — on or before March 1, 2024 and on or before each January 1 thereafter the authority shall publish allowable maximum county ground ambulance rates and submit reports to DOI, DMHC, and Office of Health Care Affordability.

Report contentReport shows allowable maximum rates for ground ambulance transportation services in each county and trends by county; may include applicable Medicare rate if feasible.

RecipientsAnnual report must be submitted to the Department of Insurance and the Department of Managed Health Care, and to the Office of Health Care Affordability.

When a member receives covered services from a noncontracting ground ambulance provider, UnitedHealthcare (as the plan/insurer) will limit the enrollee/insured cost‑sharing to the in‑network cost‑sharing amount. At the time of payment to the noncontracting provider, the plan/insurer will notify both the enrollee/insured and the noncontracting provider of the in‑network cost‑sharing amount and will disclose whether the coverage is state‑regulated. The in‑network cost‑sharing amount counts toward the member's annual out‑of‑pocket limit and toward any deductible in the same manner as for a contracting provider. A noncontracting ground ambulance provider may only advance to collections the in‑network cost‑sharing amount that the enrollee/insured failed to pay, and may not report adverse credit information or commence civil action for at least 12 months after initial billing.

Prior Authorization

Prior Authorization for Ambulance Transport

UnitedHealthcare covers ambulance transportation (ground or air) to the nearest appropriate facility when medically necessary. Use of an ambulance is covered without prior authorization when the member reasonably believes there is an emergency medical or psychiatric condition that requires ambulance transport. Ground and air transport coverage conditions and inter‑facility transfer rules apply per the benefit terms (see Emergency and Urgent Services and Medical Necessity benefit interpretations).

Ground ambulance: BLS/ALS transport when medical necessity for ground ambulance is met (including specified inter‑facility and dialysis transfers)
Air ambulance: covered only when destination is an acute care hospital and ground transport would endanger life/health, be inaccessible, or impractical due to weather/traffic
Ambulance requested by public entities covered when supplier documentation supports medical necessity or UnitedHealthcare independently determines necessity
Non‑emergency ambulance requires authorization by the member's network medical group or UnitedHealthcare

inv-13: in-network cost-sharing amount

In‑network cost‑sharing amount (air)The in‑network cost‑sharing amount is the same cost sharing the insured/subscriber would pay to a contracting air ambulance provider; the insurer must inform the insured/subscriber and provider of that amount at time of payment.

Counts to OOP and deductibleCost sharing paid under this section counts toward annual out‑of‑pocket limits and toward deductibles as if attributed to a contracting provider.

Satisfies obligationThe cost sharing paid pursuant to this section satisfies the insured's/subscriber's obligation to pay cost sharing for the health service.

inv-14: payment basis / local government rate

Local government rate basisIf a local government has an established or approved rate for the service, the insurer/plan reimburses at that rate for purposes of determining payment to a noncontracting ground ambulance provider.

Fallback rateIf no local rate exists, the amount established by Title 28 CCR 1300.71(a)(3)(B) or the reasonable and customary value (based on statistically credible data and factors) applies.

Jurisdiction ruleLocal government jurisdiction applies if the transport was initiated within that local government's regulatory boundaries or, for mutual/automatic aid transports, where the noncontracting provider is based.

inv-15: in-network cost-sharing amount

In‑network cost‑sharing amount (ground)Enrollee/insured pays no more than the in‑network cost‑sharing amount for covered services from a noncontracting ground ambulance provider; the plan/insurer must inform the enrollee/insured and provider of that amount at time of payment.

Insurer reimbursementUnless otherwise agreed, the insurer shall directly reimburse the noncontracting ground ambulance provider the difference between the in‑network cost‑sharing amount and (A) the local government rate if established, or (B) specified state/regulatory rate or reasonable & customary value if no local rate exists.

Payment constitutes full paymentA payment by the plan/insurer plus the enrollee/insured cost share constitutes payment in full, and does not establish prevailing/customary charges for other payers.

inv-16: Medically necessary ambulance transport

Medically necessary ground transportGround ambulance transportation is covered when medically necessary for transfers (inter‑hospital, SNF, dialysis, radiation therapy, hospital/home) and other ground emergency transports; use for non‑emergency requires authorization unless documentation shows medical necessity.

Air ambulance coverage conditionsAir ambulance is covered only when destination is an acute care hospital and ground transport would endanger life/health, is inaccessible or too slow, or weather/traffic make ground transport impractical.

911/emergency authorizationUse of ambulance (land or air) is covered without prior authorization when the member reasonably believes there is an emergency medical or psychiatric condition that requires ambulance transport to access emergency health care services.