Find policies, billing codes, payers, states, and providers
Ambulance Services (for New Mexico Only)
Customize your policy alerts
Sign up for UnitedHealthcare Policy CS003NM.C alerts
Get alerted when Policy CS003NM.C changes without checking for updates manually.
Monitor payer policy activity
Policy governing coverage and billing guidance for ambulance transportation services for UnitedHealthcare Community Plan members in New Mexico; applies to providers and claims processing for services in that state.
Medical Records Documentation Used for Reviews section was expanded to require documentation that fully supports medical necessity and to note that documentation may be required to assess clinical criteria but does not guarantee coverage.
Applicable Codes section updated description for revenue code 0546.
Coverage Criteria for Ambulance Services
Medical necessity (by state regulation)
Covered when state clinical criteria are met:
Follow NMAC for specific clinical conditions and authorization requirements.
Ambulance transportation is a clinical service and, as such, is not regulated by the U.S. Food and Drug Administration. FDA approval is not a basis for coverage for ambulance services; coverage determinations are made under applicable federal, state, and contractual rules rather than on FDA status.
The codes listed in this policy are provided for reference only. Listing a code does not guarantee that the service is a covered health service or that a claim will be paid. Benefit coverage and reimbursement are determined by applicable federal, state, or contractual requirements and other policies and guidelines that may apply.
Applicable Codes and Billing Rules
| A0140 | Nonemergency transport and air travel (private or commercial) intra- or interstate. |
| A0225 | Ambulance service, neonatal transport, base rate, emergency transport, one way. |
| A0380 | BLS mileage (per mile). |
| A0382 | BLS routine disposable supplies. |
| A0384 | BLS specialized service disposable supplies; defibrillation. |
| A0390 | ALS mileage (per mile). |
| A0392 | ALS specialized service disposable supplies; defibrillation. |
| A0394 | ALS specialized service disposable supplies; IV drug therapy. |
| A0396 | ALS specialized service disposable supplies; esophageal intubation. |
| A0398 | ALS routine disposable supplies. |
| 0540 | Ambulance General Classification (revenue code). |
| 0541 | Ambulance Supplies (revenue code). |
| 0542 | Ambulance Medical Transport (revenue code). |
| 0543 | Ambulance Heart Mobile (revenue code). |
| 0544 | Ambulance Oxygen (revenue code). |
| 0545 | Ambulance Air Ambulance (revenue code). |
| 0546 | Ambulance Neonatal Ambulance Services (revenue code). |
| 0547 | Ambulance Pharmacy (revenue code). |
| 0548 | Ambulance EKG Transmission (revenue code). |
| 0549 | Ambulance Other Ambulance (revenue code). |
| H | Hospital (amb origin/destination modifier). |
| R | Residence (amb origin/destination modifier). |
| S | Scene of accident or acute event (amb modifier). |
| I | Site of transfer (e.g., airport or helicopter pad) between modes of ambulance transport. |
| P | Physician's office. |
| QL | Patient pronounced dead after ambulance called (exception billing). |
| X | Intermediate stop at physician's office on way to hospital (destination code only). |
| G | Hospital-based ESRD facility. |
| J | Freestanding ESRD facility. |
| N | Skilled nursing facility. |
Provider Responsibilities, Documentation & Denial Risk
Follow NMAC § 8.324.7 for medical necessity
Medical necessity criteria for coverage are determined by New Mexico Administrative Code (NMAC) § 8.324.7: Transportation Services and Lodging; providers should refer to the state rules for any prior authorization or clinical criteria.
Refer to state rules (NMAC § 8.324.7) for authorization requirements
When requesting coverage or review, providers must follow the policy's direction to rely on applicable state rules; see NMAC § 8.324.7 for specific clinical or authorization requirements referenced by this policy.
Required medical record documentation for reviews
The patient's medical record must contain documentation that fully supports the medical necessity for the requested ambulance services and must be made available upon request.
- Include relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.
- Ensure documentation is legible and maintained in the patient's medical record.
- Provide records promptly when requested for review.
Documentation-related denial risk
Failure to provide medical record documentation that fully supports medical necessity may result in denial or an inability to determine coverage.
- Lack of legible or complete documentation can lead to claim denial.
- Documentation that does not demonstrate meeting NMAC § 8.324.7 clinical criteria may be insufficient for coverage.
Background
Ambulance transportation is a medical transport service used to move members who require emergency or nonemergency transport based on clinical need. Coverage for ambulance services in New Mexico is contingent on meeting the medical necessity clinical criteria set forth in New Mexico Administrative Code (NMAC) § 8.324.7. Providers should follow state rules for specific clinical conditions, authorization requirements, and any applicable documentation expectations.
Definitions and Modifier/Code Notes
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.