CurrentUnitedHealthcarePolicy CS003ID.B

Ambulance Services (Idaho)

Policy governing ambulance (air and ground) transportation services for UnitedHealthcare Community Plan members in Idaho; medical necessity criteria are provided in the Idaho Medicaid Provider Handbook.

Policy Summary

PayerUnitedHealthcare

PolicyAmbulance Services (Idaho)

Policy CodePolicy CS003ID.B

Change TypeClinical criteria delegated to state handbook

Effective DateNov 1, 2025

Next Review DateN/A

Key ActionProviders must consult the Idaho Medicaid Provider Handbook, Transportation Services, for medical necessity and prior authorization requirements.

SourceLink

POLICY UPDATE CHANGES

Replaced coverage guidelines with instruction to refer to the Idaho Medicaid Provider Handbook, Transportation Services for medical necessity clinical coverage criteria.

Removed multiple definitions including Air Ambulance, Emergency, Medically Necessary, and facility definitions.

Removed Description of Services, Benefit Considerations, and Clinical Evidence sections.

Archived previous policy version CS003ID.A.

1 statepolicy applies to

dozensambulance codes listed

Idaho Medicaid Handbookmedical necessity source

CS003ID.A

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Coverage and Medical Necessity

Medical Necessity Criteria (external)

Coverage and medical necessity determined by external Idaho Medicaid guidance

Referential criteria: Medical necessity clinical coverage criteria are contained in the Idaho Medicaid Provider Handbook, Transportation Services; this policy does not reproduce those criteria.

Providers must consult the Idaho Medicaid Provider Handbook for the specific conditions under which ambulance transport is medically necessary.

The inclusion of a procedure or diagnosis code in this policy is for reference only and does not imply coverage, reimbursement, or a right to payment. Benefit coverage is determined by applicable federal, state, and contractual requirements and laws; other policies and guidelines may also apply. Providers must verify coverage and payment entitlement before billing.

This policy does not enumerate specific Not Medically Necessary conditions. Determinations about services that are not medically necessary are made according to the Idaho Medicaid Provider Handbook, Transportation Services, and any applicable contractual or regulatory requirements. Providers should consult the Idaho Medicaid Provider Handbook for guidance on denial or NMN decisions.

Ambulance and Billing Codes

Air Ambulance and selected ground/other ambulance codes (group 1)HCPCS

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 (1/2) hour increments
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)

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Ground and other ambulance codes (group 2)HCPCS

A0422	Ambulance (ALS or BLS) oxygen and oxygen supplies, life sustaining situation
A0424	Extra ambulance attendant, ground (ALS or BLS) or air (fixed or rotary winged); requires medical review
A0425	Ground mileage, per statute mile
A0426	Ambulance service, advanced life support, nonemergency transport, level 1 (ALS 1)
A0427	Ambulance service, advanced life support, emergency transport, level 1 (ALS 1 emergency)
A0428	Ambulance service, basic life support, nonemergency transport (BLS)
A0429	Ambulance service, basic life support, emergency transport (BLS, emergency)
A0432	Paramedic intercept (PI), rural area, transport furnished by a volunteer ambulance company prohibited by state law from billing third-party payers
A0433	Advanced life support, level 2 (ALS 2)
A0434	Specialty care transport (SCT)

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Revenue codesRevenue

0540	Ambulance-General Classification
0541	Ambulance-Supplies
0542	Ambulance-Medical Transport
0543	Ambulance-Heart Mobile
0544	Ambulance-Oxygen
0545	Ambulance-Air Ambulance
0546	Ambulance-Neonatal Ambulance Services
0547	Ambulance-Pharmacy
0548	Ambulance-EKG Transmission
0549	Ambulance-Other Ambulance

Ambulance ModifiersModifier

D	Diagnostic or therapeutic site other than place of pick-up or hospital when these are used as origin codes
E	Residential, domiciliary, custodial facility (other than 1819 facility)
G	Hospital-based ESRD facility
H	Hospital
I	Site of transfer (e.g., airport or helicopter pad) between mode of ambulance transport
J	Freestanding ESRD facility
N	Skilled nursing facility
P	Physician's office
R	Residence
S	Scene of accident or acute event

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Provider Billing & Operational Actions

Documentation Required

Code listing is not authorization

Listing of a code in this policy does not imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by federal, state, or contractual requirements and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claim payment. Other Policies and Guidelines may apply.

Applicable codes lists are provided for reference only and are not authorization for payment.

Billing Rule

Modifier billing instructions

Ambulance claims must be billed with two modifiers: the first modifier indicates the place of origin and the second modifier indicates the destination. Use the following modifiers as appropriate when billing:

Background

This policy governs ambulance transportation (ground and air) services for members in Idaho but defers clinical medical necessity determinations to the state guidance. For specific clinical criteria describing when ambulance transport is medically necessary, providers must refer to the Idaho Medicaid Provider Handbook, Transportation Services. The policy provides ambulance coding and billing references but does not reproduce the clinical coverage rules.

Definitions

Definitions removed — refer to Idaho Medicaid Provider Handbook

Current definitions statusPrior detailed definitions (Air Ambulance; Covered Health Care Service(s); Emergency; Emergency Health Care Services; LTAC; Medically Necessary; Short-Term Acute Care Facility; Sub-Acute Facility) were removed from this policy.

Where to find clinical definitionsThis policy defers to the Idaho Medicaid Provider Handbook, Transportation Services for clinical definitions and medical necessity criteria.

Policy history noteChange effective 11/01/2025: definitions removed and previous policy version CS003ID.A archived.

Removed supporting sectionsDescription of Services, Benefit Considerations, and Clinical Evidence sections were removed in this revision.

Action for providersConsult the Idaho Medicaid Provider Handbook for authoritative definitions when preparing authorizations or documentation.

Revision History & Policy Changes

Material change in this version: the policy’s clinical coverage criteria have been removed and replaced with a directive to consult the Idaho Medicaid Provider Handbook, Transportation Services for medical necessity criteria. Several prior definitions and supporting sections were removed and the previous policy version CS003ID.A was archived.