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Ambulance Services (for Tennessee Only)
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Policy governing medical necessity, coverage, coding, and billing for emergency and non-emergency ambulance services for UnitedHealthcare Tennessee Medicaid and CoverKids members.
Coverage Rationale Non-Emergency Transportation instruction updated to refer to TennCare Medicaid § 1200-13-13-.04 for medical necessity clinical coverage criteria.
Definition of 'Independent Freestanding Emergency Department' was added.
Clinical Evidence and References sections updated to reflect the most current information.
Coverage Criteria for Ambulance Services
Emergency Air Ambulance - Medically Necessary
Emergency Air Ambulance services are considered medically necessary when ALL of the following are met:
From Coverage Rationale
From Coverage Rationale
From Coverage Rationale
Emergency Ground Ambulance - Medically Necessary
Emergency ground ambulance services are considered medically necessary when ALL of the following are met:
From Coverage Rationale
From Coverage Rationale
From Coverage Rationale
Emergency ground ambulance - treatment without transport
Emergency ground ambulance services without ground transportation (treatment at scene) are considered medically necessary when ALL of the following are met:
From Coverage Rationale
Claims/medical necessity documentation requirement
Non-Emergency Interfacility Ambulance - Covered
Non‑Emergency ambulance transportation between facilities is covered when ONE of the following is met:
From Benefit Considerations; documentation must support necessity per TennCare § 1200‑13‑13‑.04 and plan rules
From Benefit Considerations; documentation must support that alternative transport would endanger the member's health
From Benefit Considerations; prior authorization may be required depending on plan
Non-Emergency Ambulance Coverage
Covered non‑emergency interfacility ambulance transport when ANY one of the following is met:
Providers must document clinical need and include appropriate ambulance modifiers and HCPCS/CPT/Revenue codes on claims
Documentation must show that other transportation would endanger the member's health; prior authorization may be required
Claims should include origin/destination modifiers; failure to follow TennCare § 1200‑13‑13‑.04 may result in denial
Air Medical Transport Indications
Air medical transport is appropriate when ONE of the following primary patient‑centered goals is met:
Ground EMS (GEMS) is preferred when it can meet critical care expertise and timely transport needs; air should be used only when aligned with these goals
From joint position statements
From Coverage Rationale and evidence summaries
Trauma Triage and Transport
Triage to the highest‑level trauma center when ALL of the following are considerations:
EMS judgment should also consider age, anticoagulant use, suspected child abuse, pregnancy, burns, and high‑resource needs; consider air medical services when appropriate
From field triage guidance and clinical evidence
Emergency ambulance services (air and ground) are considered medically necessary only when they meet the specified criteria in this policy. For air ambulance, medical necessity requires that ground transport times are excessive (typically 30–60 minutes or longer) or ground transport is impractical due to weather/traffic or inaccessible pickup location; the member must be transported to the nearest acute care hospital that can meet their needs; and services must be requested by police/medical authorities at the scene of an Emergency or advanced/basic life support must be required during transport. For ground ambulance, medical necessity requires an immediate need for transport to the nearest appropriate facility (including neonatal special care units or a hospital providing a higher level of care), a delay would endanger life or seriously jeopardize health, and advanced/basic life support is required during transport.
Services are not eligible for coverage when provided by ambulance providers who are not properly licensed, when Air Ambulance transport does not meet the Air Ambulance covered indications described in this policy, or when another mode of transportation would be appropriate. Ambulance transport for member convenience or nonmedical reasons (for example, personal preference for a particular hospital or routine services where other transport is feasible) is excluded from coverage and may be denied.
Ambulance transportation is a health care service (ground, air, or water) used to move members when required by illness or injury. As a service, ambulance transportation is not subject to U.S. Food and Drug Administration regulation; this information is provided for context and does not affect coverage determinations.
Emergency ground ambulance transportation that does not meet the policy's listed criteria is not considered medically necessary. Covered emergency ground transport requires an immediate need to reach the nearest appropriate facility (including neonatal special care units or a facility providing a higher level of care), that a delay may endanger the member's life or health, and that advanced or basic life support is required during transport. Treatment rendered on scene by ground EMS personnel without subsequent transport is considered medically necessary only when care is actually provided on scene by those personnel.
Ambulance transport is not covered when other transportation modes would not endanger the member's health or when transport is for convenience or nonmedical reasons. For non-emergency interfacility transfers, documentation must demonstrate that ambulance transport was required (for example, transfer to the closest network facility that provides the required services) and that alternative transport would have endangered the member; absent that documentation, the claim may be excluded.
Air medical transport should be reserved for situations aligned with primary patient-centered goals: initiation or continuation of advanced/specialty care not available locally; expedited delivery for time-sensitive definitive care; or extraction/evacuation from environments that limit timely access. When Ground EMS (GEMS) resources can meet the patient's critical care needs and provide timely transport to definitive care, GEMS is preferred and should be used; GEMS clinicians should be empowered to cancel air responses when air transport would place crews at undue risk or does not meet the stated goals. Air transport is additionally justified when ground times are excessive (e.g., 30–60 minutes or longer) or when weather, traffic, or inaccessible pickup points make ground transport impractical.
Denial risk when emergency transport criteria not met
Requests for emergency air or ground ambulance transport that do not meet the policy's medical necessity criteria may be denied. Examples include lack of immediate need for transport, destination not the nearest acute care hospital that can meet the member's needs, failure to show that delay would endanger life or health, or absence of required ALS/BLS during transport.
- Air ambulance: denial if ground transport times are not excessive (30–60 minutes or longer), weather/traffic do not make ground impractical, or pickup point is accessible by ground [[cited above]].
- Emergency transports may be denied if the member's destination is not the nearest acute care hospital that can meet the member's needs.
- Denial risk when documentation does not support that a delay in transportation time may endanger the member's life or seriously endanger the member's health.
- Denial risk when ALS or BLS is not required during transport but was billed as emergency transport.
Coverage exclusions that trigger denial
Certain services are excluded and will trigger claim denial: transports provided by unlicensed ambulance providers; air ambulance when the specific air-transport indications are not met; ambulance when another mode of transportation is appropriate; or transports provided for member convenience or nonmedical reasons.
- Do not bill for ambulance services delivered by providers not properly licensed to perform the ambulance services.
- Air ambulance will be denied if the transport does not meet the Air Ambulance covered indications in the policy.
- Non-emergency ambulance claims will be denied when other transportation modes are appropriate or when transport is for member convenience (e.g., preference for a particular hospital or routine services that could use other modes).
Coding and Billing Codes
| A0430 | Ambulance service, conventional air services, transport, one way (fixed wing) |
| A0431 | Ambulance service, conventional air services, transport, one way (rotary wing) |
| A0435 | Fixed wing air mileage, per statute mile |
| A0436 | Rotary wing air mileage, per statute mile |
| S9960 | Ambulance service, conventional air services, nonemergency transport, one way (fixed wing) |
| S9961 | Ambulance service, conventional air service, nonemergency transport, one way (rotary wing) |
| T2007 | Transportation waiting time, air ambulance and nonemergency vehicle, one-half hour increments |
| A0225 | Ambulance service, neonatal transport, base rate, emergency transport, one way |
| A0380 | BLS mileage (per mile) |
| A0392 | ALS mileage (per mile) |
| D | Diagnostic or therapeutic site other than p or H when these are used as origin codes |
| E | Second modifier indicates the destination |
| G | Residential, domiciliary, custodial facility (other than 1819 facility) |
| H | Hospital |
| I | Site of transfer (e.g., airport or helicopter pad) between modes of ambulance transport |
| N | Skilled nursing facility |
| P | Physician's office |
| QL | Patient pronounced dead after ambulance called (billed in place of origin/destination combo) |
| R | Residence |
| S | Scene of accident or acute event |
Prior Authorization, Documentation, and Provider Responsibilities
Non-emergency prior authorization reference (TennCare § 1200-13-13-.04)
For non-emergency ambulance medical necessity determinations, follow the Tennessee Department of Finance and Administration, Bureau of TennCare § 1200-13-13-.04: TennCare Medicaid, Covered Services; providers must also follow applicable state or contractual prior authorization requirements.
Prior authorization for non-emergency transport
Prior authorization rules vary by plan: some plans may require prior authorization for non-emergency ground ambulance transport, and prior authorization is required for non-emergency Air Ambulance transport.
- Check federal, state, and contractual requirements for plan-specific prior authorization for non-emergency ground ambulance.
- Obtain prior authorization for any non-emergency Air Ambulance transfer.
Air medical use limited to specified goals (TennCare referenced)
Use of air medical transport should be limited to: initiation/continuation of advanced or specialty care not available locally; expedited delivery for time-sensitive definitive care; or extraction/evacuation from environments that limit timely access — and providers should reference TennCare rules for non-emergency prior authorization requirements.
- Air medical transport is appropriate only when it aligns with one of the three primary patient-centered goals.
- GEMS is preferred if it can meet the patient's critical care and timely transport needs.
Obtain required authorizations and document transport decisions
Ensure prior authorization, documentation, and clinical justification are obtained per plan rules before billing; follow applicable state/contractual requirements and the policy's documentation guidance.
- Confirm the mode of transport is determined by appropriate authorities (e.g., first responders, ED physician).
- Obtain required authorizations and document the clinical reasons if non-emergency transport is used.
Transport mode escalation and limitations for non-emergency transfers
Non-emergency interfacility ambulance coverage is limited to transfers that meet specified facility or clinical reasons (e.g., transfer to the closest network hospital or to a facility that provides required covered services) — other transportation modes must be used when appropriate before ambulance is covered.
- Covered interfacility reasons include transfers from out-of-network to closest network hospital, to a facility providing required services not available locally, or from STAC to LTAC/rehab/Sub-Acute facilities.
- If other transportation is appropriate, ambulance coverage may be excluded.
Preference for Ground EMS when appropriate
Ground EMS (GEMS) should be used when GEMS resources can meet the patient's critical care needs and provide timely transport; on-scene GEMS clinicians should be empowered to cancel air medical response if continuing would place crews at undue risk or not meet the air transport goals.
- Prefer GEMS when it can provide necessary critical care expertise and timely transport.
- GEMS clinicians may cancel air response if unsafe or not aligned with primary goals.
Claims must include correct modifiers and procedure codes
Include appropriate ambulance origin and destination modifiers and the relevant HCPCS/CPT/Revenue codes on claims as listed in the policy; listing codes is for reference and inclusion does not guarantee coverage.
- Bill ambulance claims with two modifiers indicating origin and destination (or QL when applicable).
- Include applicable HCPCS/CPT/Revenue codes referenced in the policy.
Document transport rationale for non-emergency interfacility transfers
Documentation must demonstrate that non-emergency interfacility ambulance transport met a covered reason (e.g., transfer to the closest network hospital providing required services or transfer from STAC to LTAC/rehabilitation/Sub-Acute) and that alternative transportation would have endangered the member's health; otherwise the claim may be excluded.
- Document the specific covered reason for the transfer and why other transport was inappropriate or unsafe.
- Retain records showing destination facility capability and network status when applicable.
Medical necessity determination and Certificate for scene transports
For scene transports (including air), medical necessity is determined by the requesting authorized provider's judgment and regional policy; a receiving physician or the transport program medical director may complete the Certificate of Medical Necessity for scene transports when appropriate.
- Rely on the requesting provider's medical judgment and regional protocols to determine scene transport necessity.
- Receiving physician or transport medical director may complete the Certificate of Medical Necessity on scene transports.
Non-Emergency transport reference and denial risk (TennCare § 1200-13-13-.04)
Failure to follow TennCare medical necessity criteria (TennCare § 1200-13-13-.04) for non-emergency transportation may result in denial or recoupment of payment.
Background and Evidence
Ambulance services include transport by ground, air (rotary or fixed wing), or water when required by the severity or nature of illness or injury. Mode selection is determined by clinical need and appropriate authorities; air ambulance is reserved for situations where ground transport is impractical, delayed, or unable to provide timely lifesaving care.
Definitions
Policy Revision History
Coverage Rationale for Non-Emergency Transportation updated to reference TennCare Department of Finance and Administration, Bureau of TennCare § 1200-13-13-.04 for medical necessity clinical coverage criteria (replacing prior Tennessee statewide contract/compilation citation); definition added for 'Independent Freestanding Emergency Department'; Clinical Evidence and References updated; previous policy version CS003TN.Q archived.
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