CurrentUnitedHealthcarePolicy CS003LA.P

Ambulance Services (for Louisiana Only)

Defines Louisiana Medicaid (applied by UnitedHealthcare for Louisiana) coverage, billing, provider requirements, and reimbursement rules for ambulance services (ground and air), including emergency, non-emergency (NEAT), treatment-in-place, transfers, mileage, modifiers, exclusions, attendant rules, and facility-specific billing.

Policy Summary

PayerUnitedHealthcare

PolicyAmbulance Services (for Louisiana Only)

Policy CodePolicy CS003LA.P

Change TypeCoding and coverage updates

Effective DateOct 1, 2025

Next Review Date

Key ActionAmbulance providers must retain documentation supporting that at least one emergency criterion was met and that beneficiary would be susceptible to injury using any other transportation method; documentation may be requested in post-payment review.

POLICY UPDATE CHANGES

Revised coverage rationale to replace 'Southeastrans' with 'Verida (formerly Southeastrans)'.

Removed reference to HCPCS code A0226 from Ambulance Service Exclusions.

Added notation that specified HCPCS codes are not on the State of Louisiana Medicaid Fee Schedule and therefore may not be covered (A0225, A0380, A0384, A0390, A0392, A0396, A0420, A0424, A0432, A0998, S0207, S0208, S9960, S9961, T2007).

Added HCPCS codes S9960, S9961, and T2007 to the Air Ambulance section.

Added multiple HCPCS codes to the Ground/Other Ambulance section (A0225, A0380, A0382, A0384, A0390, A0392, A0396, A0420, A0424, A0432, A0998, S0207, S0208).

Revised References section and archived previous policy version CS003LA.O.

ManyHCPCS/Modifiers Listed

Emergency: no PAPrior Authorization

≤180 daysCertification Duration

Policy Summary

This UnitedHealthcare medical policy implements Louisiana Medicaid ambulance service rules (state-specific) and aligns with LDH Bureau of Emergency Medical Services licensing and La. R.S. requirements. It covers emergency and non-emergency ground and air ambulance services, treatment-in-place (physician-directed telehealth facilitated by ambulance providers), transfers/return trips, mileage, place-of-origin/destination modifiers, attendant rules, and facility-specific billing. UnitedHealthcare applies these rules according to enrollment type: managed care organizations (MCOs) vs fee-for-service (FFS) responsibilities vary by population (for example, NEAT vs emergency assignments differ by enrollee group and setting).

Effective date: October 1, 2025; Last review: October 1, 2025.

Policy metadata

Policy NumberCS003LA.P

SubjectAmbulance Services (Louisiana Medicaid)

PayerUnitedHealthcare

StatusCURRENT

Effective Date2025-10-01

Last Review2025-10-01

Next Review

Certification duration thresholdCAT date range <= 180 days

Coverage Criteria and Scope

Emergency Ambulance Transportation - Medical Necessity

Emergency ambulance transportation is covered when ANY of the following are met (prudent layperson standard):

Emergency criteria (prudent layperson)

Acute symptoms jeopardy: Condition manifests acute symptoms of sufficient severity such that a prudent layperson could reasonably expect that absence of immediate medical attention would place the beneficiary's health in serious jeopardy
Serious impairment: Condition would result in serious impairment to bodily functions
Serious dysfunction: Condition would result in serious dysfunction of any bodily organ or part

Code Lists and Modifiers

Treatment-in-Place Telehealth / Informational CodesHCPCS

G2021	Identifier for treatment-in-place telehealth services; accepted/paid $0.00
G2022	Informational code for beneficiary refusal of treatment-in-place; accepted/paid $0.00 (optional)

Place-of-origin and destination modifiers (two-digit state-specific)Modifier

DD	Trip from DX/Therapeutic Site to another DX/Therapeutic Site
DE	Trip from DX/Therapeutic Site to Residential, Domiciliary, Custodial Facility
DH	Trip from DX/Therapeutic Site to Hospital
DI	Diagnostic-Therapeutic Site/Transfer Airport Heli Pad
DJ	Diagnostic/therapeutic site other than P/H to a Non-Hospital-based Dialysis facility
DN	Trip from DX/Therapeutic Site to Skilled Nursing Facility (SNF)
DP	Trip from DX/Therapeutic Site to Physician's Office
DR	Trip from DX/Therapeutic Site to Home
DX	Trip from DX/Therapeutic Site to MD to Hospital
ED	Trip from an RDC or Nursing home to DX/Therapeutic Site

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Codes Not on LA Medicaid Fee Schedule (may not be covered)HCPCSExperimental

A0225	Ambulance service, neonatal transport, base rate, emergency transport, one way
A0380	BLS mileage (per mile)
A0384	BLS specialized service disposable supplies; defibrillation
A0390	ALS mileage (per mile)
A0392	ALS specialized service disposable supplies; defibrillation
A0396	ALS specialized service disposable supplies; esophageal intubation
A0420	Ambulance waiting time (ALS or BLS), one-half hour increments
A0424	Extra ambulance attendant, ground (ALS or BLS) or air; requires medical review
A0432	Paramedic intercept (PI), rural area, transport furnished by volunteer ambulance company
A0998	Ambulance response and treatment, no transport

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Billing, Documentation & Operational Rules

Documentation Required

Emergency transport documentation retention

Retain documentation demonstrating that at least one emergency criterion was met and that the beneficiary would be susceptible to injury if transported by another method. This documentation may be requested in a post-payment review.

Documentation that at least one emergency criterion was met (per prudent layperson standard)
Evidence beneficiary would be susceptible to injury using other transportation methods
Available for submission during post-payment review

Prior Authorization

Prior approval not required for emergency ambulance

MCOs may not require prior authorization for emergency ambulance transportation. Claims are reviewed retrospectively and the MCO may conduct post-payment review; clinical documentation is not required to be submitted with the claim but may be requested after claim submission.

Key Terms

Key definitions

Basic Life Support (BLS)Provision of medically necessary supplies and services by EMS practitioners licensed at least to the level of an emergency medical technician.

Advanced Life Support (ALS)Provision of medically necessary supplies and services by EMS practitioners licensed at least to the level of an advanced emergency technician or equivalent.

Specialty Care Transport (SCT)Interfacility transport of a critically injured or ill beneficiary by ground ambulance at a level beyond EMT-Paramedic scope.

Treatment-in-PlacePhysician-directed facilitation of a telehealth visit by an ambulance provider where care is provided on scene without transport. Each paid treatment-in-place ambulance claim must have a separate corresponding paid treatment-in-place telehealth claim (G2021) or a separate paid ambulance transportation claim; reimbursement for both treatment-in-place and emergency transport for same incident is not permitted.

Policy Changes

10/01/2025revised

Replaced 'Southeastrans' with 'Verida (formerly Southeastrans)' in coverage rationale.

10/01/2025removedLatest

Removed reference to HCPCS code A0226 from Ambulance Service Exclusions.

10/01/2025addedLatest

Policy Summary

PayerUnitedHealthcare

PolicyAmbulance Services (for Louisiana Only)

Policy CodePolicy CS003LA.P

Change TypeCoding and coverage updates

Effective DateOct 1, 2025

Next Review Date

On This Page

Psychiatric unmanageable or restraint: Beneficiary is psychiatrically unmanageable or needs restraint

Non-Emergency Ambulance Transportation (NEAT) - Coverage Requirements

NEAT is covered when ALL of the following are met:

NEAT coverage requirements

Transport to/from Medicaid covered service: Transport is to and/or from a Medicaid covered service (including carved-out services or value-added benefits) or nearest appropriate facility
No other means available / contraindicated: No other means of transportation is available and beneficiary's condition contraindicates other methods or would make beneficiary susceptible to injury
Certification of Ambulance Transportation (CAT) completed by an authorized certifying authority (treating physician, RN, director of nursing at nursing facility, NP, PA, or CNS) describing medical condition and date range<= 180 days
CAT date range shall be no more than 180 days; a single CAT may cover multiple transports within the date range
Scheduling and verification: NEAT must be scheduled through the transportation broker or ambulance provider and verifier must confirm enrollee eligibility, originating/destination address is a medical facility, and completed CAT obtained/accepted
If scheduled through MCO or provider, completed CAT must be on file or submitted with clean claim prior to reimbursement

Air Ambulance Coverage Conditions

Air ambulance services are covered only when ONE of the following is met:

Air ambulance coverage conditions

Point inaccessible by land: Speedy admission is essential and point of pick-up is inaccessible by land vehicle
Great distances or obstacles: Great distances or other obstacles are involved in getting beneficiary to nearest hospital with appropriate services

Treatment-in-Place - Coverage and Billing Rules

Treatment-in-place services are covered only under specified conditions and billing rules:

Treatment-in-place coverage and billing rules

Telehealth pairing requirement: Each paid treatment-in-place ambulance claim must have a separate and corresponding paid treatment-in-place telehealth claim (and vice versa) or a separate paid ambulance transportation claim
G2021 must be billed for telehealth; G2021 accepted/paid $0.00; include POS '02' or '10' and modifier '95'
No dual reimbursement with emergency transport: Reimbursement for both an emergency transport to a hospital and an ambulance treatment-in-place service for the same incident is not permitted
If deterioration necessitates immediate transport, bill transport only
Mileage billed with treatment-in-place denied: If treatment-in-place claim is billed with mileage the entire claim will be denied
Operational denial rule
Unpayable line denial: If an unpayable procedure code (not mileage) is billed on a treatment-in-place claim, only the line with the unpayable code will be denied
Telehealth procedure code and modifiers: Claims for allowable telehealth procedure codes must be billed with procedure code G2021; providers must include POS '02' or '10' and modifier '95' for telehealth claims
G2021 accepted/paid at $0.00
Beneficiary refusal informational code: If beneficiary declines treatment-in-place, provider may include optional informational procedure code G2022 (paid at $0.00) to identify refusal
Use of G2022 is optional and does not affect medical necessity determination

Transfers and Return Trips

Coverage rules for transfers and return trips:

Transfers and return trip rules

Inter-hospital transfers medically necessary: Ambulance transfer between hospitals must be medically necessary and to the most appropriate hospital; provider reimbursed for both transfers when clean claims submitted
NEMT return trip request: When transported to hospital on emergency basis and not admitted, hospital must request NEMT return trip with transportation broker unless beneficiary meets medical necessity for NEAT

Documentation Required

Certification for NEAT (CAT) required

A completed Certification of Ambulance Transportation (CAT) must be obtained from an authorized certifying authority and either attached with the clean claim or be on file with the MCO/transportation broker prior to reimbursement. The CAT must include a date range no greater than 180 days.

Authorized certifying authorities: treating physician, registered nurse, director of nursing at nursing facility, nurse practitioner, physician assistant, clinical nurse specialist
CAT date range must be no more than 180 days
Completed CAT must be submitted with the clean claim or be on file with the MCO/transportation broker prior to reimbursement

Billing Rule

Modifiers required for A0425-A0429, A0433-A0434, A0436

Enter a valid 2-digit place-of-origin/destination modifier appended to the 5-digit procedure code (no spaces) when billing the listed codes.

Affected codes: A0425, A0426, A0427, A0428, A0429, A0433, A0434, A0436
Enter valid 2-digit place-of-origin/destination modifier appended to the 5-digit code; do not include spaces

Billing Rule

Mileage billing constraint

Mileage reimbursement is limited to actual miles from pick-up to delivery and may be billed only for miles traveled with the beneficiary aboard the ambulance.

Mileage limited to actual mileage from point of pick-up to point of delivery
Mileage can only be billed for miles traveled with the beneficiary in the ambulance

Billing Rule

Treatment-in-place telehealth pairing requirement

Treatment-in-place telehealth claims must be paired: each paid treatment-in-place ambulance claim must have a corresponding paid telehealth claim billed with G2021. Telehealth claims must include POS '02' or '10' and modifier '95'. Note: G2021 is accepted/paid at $0.00.

Required telehealth procedure code: G2021 (accepted/paid $0.00)
Required POS: '02' or '10'
Required modifier: '95'

Billing Rule

Treatment-in-place mileage denial

Operational denial: if a treatment-in-place ambulance claim is billed with mileage, the entire claim will be denied.

Billing Rule

Refusal code optional

If a beneficiary declines treatment-in-place services, providers may optionally bill informational code G2022 to identify the refusal; G2022 is accepted/paid at $0.00 and its use is optional.

Informational code: G2022 (accepted/paid $0.00)
Use is optional and does not affect medical necessity determination

Documentation Required

Hospital-based ambulance billing

If a hospital admits an inpatient transported by its own hospital-based ambulance, ambulance charges must be billed as part of the inpatient hospital services. Hospitals must submit a copy of EMS certification to Provider Enrollment to be recognized to bill ambulance services.

Inpatient transports by hospital-based ambulance are billed as part of inpatient hospital services
Hospitals must submit EMS certification to Provider Enrollment to bill ambulance services

Billing Rule

Air ambulance certification requirement

Air ambulance codes listed require certification: affected air codes are A0430, A0431, A0435, A0436. Bureau of Health Services Financing certification and LDH Bureau of EMS licensure are required for Medicaid reimbursement.

Affected air codes: A0430, A0431, A0435, A0436
Must be certified by the Bureau of Health Services Financing and licensed by LDH Bureau of EMS

Denial Risk

Non-emergency 911 services non-covered

Ambulance 911 non-emergency services are not covered by Medicaid. Providers must code and bill these non-covered services using modifiers GY, QL, or TQ. Providers may bill the beneficiary only if informed consent (verbal and written) was obtained and a signed statement documenting the informed consent is on file.

Required modifiers for non-covered 911 services: GY, QL, TQ
Beneficiary may be charged only with documented informed consent (verbal and written) and a signed statement

Billing Rule

Additional passengers

The transportation broker prohibits charging or reimbursement for additional passengers. Claims submitted for transporting additional passengers will not be reimbursed.

Broker prohibits charging beneficiary or others for additional passengers
Claims for transporting additional passengers will not be reimbursed

Added notation that specified HCPCS codes are not on the State of Louisiana Medicaid Fee Schedule and therefore may not be covered. Note: Codes added to the 'not on fee schedule' notation include A0225, A0380, A0384, A0390, A0392, A0396, A0420, A0424, A0432, A0998, S0207, S0208, S9960, S9961, and T2007.

10/01/2025addedLatest

Added HCPCS codes S9960, S9961, and T2007 to Air Ambulance section.

10/01/2025addedLatest

Added multiple HCPCS codes to Ground/Other Ambulance section (A0225, A0380, A0382, A0384, A0390, A0392, A0396, A0420, A0424, A0432, A0998, S0207, S0208).

10/01/2025revised

Updated References section to reflect most current information and archived previous policy version CS003LA.O.