CurrentUnitedHealthcarePolicy CS003NJ.P

Ambulance Services (for New Jersey Only)

Medical policy governing coverage, criteria, and coding for emergency and non-emergency ambulance (ground and air) services for UnitedHealthcare Community Plan members in New Jersey.

Policy Summary

PayerUnitedHealthcare

PolicyAmbulance Services (for New Jersey Only)

Policy CodePolicy CS003NJ.P

Change TypeUpdated definitionsNJ fee-schedule notation

Effective DateSeptember 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization when required for non-emergency air or ground ambulance transfers per plan and state rules.

SourceLink

POLICY UPDATE CHANGES

Updated definitions for Emergency Services and Medically Necessary.

Added notation that HCPCS code A0140 is not on the State of New Jersey Medicaid Fee Schedule and therefore may not be covered by the State of New Jersey Medicaid program.

Removed prior notation that HCPCS codes A0426 and A0430 are not on the State of New Jersey Medicaid Fee Schedule.

Updated Clinical Evidence and References sections to reflect the most current information.

NJpolicy applies to state

30-60 minground transport threshold

Prior authnon-emergency air ambulance

A0430,A0431...HCPCS codes listed

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3HCPCS codes with NJ notation

Coverage Criteria for Ambulance Services

Emergency Air Ambulance - Medically Necessary

Covered when ALL of the following are met:

Air Ambulance - overall: All of the following must be true for Emergency Air Ambulance Services to be medically necessary

Reason ground transport inappropriate: The member's medical condition requires immediate transportation that cannot be provided by ground ambulance and a delay in transportation time may endanger the member's life or seriously endanger the member's health; examples include excessive ground transport times (30-60 minutes or longer), weather or traffic conditions making ground transport impractical or impossible, or pickup point inaccessible by ground ambulance

Examples listed in policy

Destination and care: The member's destination is the nearest acute care hospital that can meet the member's needs

Additional conditions: One of the following: services requested by police or medical authorities at the site of an emergency; OR advanced or basic life support is required during transportation

Emergency Ground Ambulance - Medically Necessary

Covered when ALL of the following are met:

Ground Emergency - immediate transport need: The member's medical condition requires immediate transportation to the nearest acute hospital that can provide appropriate services, or to the nearest neonatal special care unit for newborns, or to a hospital that provides a required higher level of care not available at the original hospital

Delay risk: A delay in transportation time may endanger the member's life or seriously endanger the member's health

Level of care during transport: Advanced or basic life support is required during transportation

Emergency Ground Ambulance - Response and Treatment No Transport

On-scene treatment only: Emergency ground ambulance services without ground transportation are medically necessary when treatment is rendered by emergency ground ambulance personnel at the scene

Non-Emergency Ambulance (Ground and Air) - Covered Transfers

Covered when ANY of the following facility-transfer conditions are met:

Interfacility coverage rules: Transport between facilities when one of the following applies: from an out-of-network hospital to the closest network hospital when covered services are required; to the closest network hospital or facility that provides required covered services not available at the original hospital or facility; or from a short-term acute care facility to the closest network LTAC, inpatient rehabilitation, or other network sub-acute facility where the required covered services can be delivered

Appropriateness criteria for air medical transport

Air medical services are appropriate when any of the following patient-centered goals are met:

Primary patient-centered goals: Initiation or continuation of advanced or specialty care not otherwise available locally; OR expedited delivery to definitive care for time-sensitive interventions; OR extraction/evacuation/rescue from environments that limit timely access or GEMS response

From NAEMSP/ACEP/AMPA joint statement

Prefer GEMS when able: Ground EMS (GEMS) transport is preferred when the patient's clinical need for critical care expertise and timely transport to definitive care can be met by GEMS; GEMS clinicians may cancel air response if continuing would place air or ground crews at undue risk or would not align with the primary patient-centered goals

From NAEMSP/ACEP/AMPA joint statement

Field triage high-risk triggers: Patients meeting high-risk physiologic or anatomic field-triage criteria (e.g., penetrating injuries to head/torso/proximal extremities, suspected spinal injury with new motor/sensory loss, unstable vital signs such as motor GCS <6 or age-adjusted hypotension, respiratory distress) should be triaged to the highest-level trauma center and air transport may be considered when feasible

Coverage exclusions include services from providers who are not properly licensed to perform the ambulance services rendered. Air ambulance transports that do not meet the policy's specified air ambulance indications are not eligible for coverage. Ambulance transportation that is appropriate by another mode (for example, when ground or other transportation would not endanger the member's health) is excluded. Transportation provided for member convenience or preference (such as choosing a specific hospital for personal reasons or routine services when the member is medically able to use other means) is also not covered.

The policy notes that high-quality randomized trial data comparing helicopter emergency medical services (HEMS) to ground EMS (GEMS) are lacking. A Cochrane review (Galvagno et al., 2015) identified only non-randomized studies and found substantial heterogeneity across studies, unclear or high selection bias, and overall low-quality evidence. The reviewers were unable to produce an accurate pooled estimate of mortality benefit for HEMS; some adjusted observational studies suggested benefit in specific settings (for example, inter-facility transfer to higher-level trauma centers), but the body of evidence does not provide conclusive, generalizable mortality benefit for routine HEMS use.

Per the policy history, HCPCS code A0140 has been added as a notation that it is not listed on the State of New Jersey Medicaid Fee Schedule and therefore may not be covered by the State of New Jersey Medicaid program. This is a state fee-schedule coverage notation and not a change to national coverage criteria.

Emergency Air Ambulance Services are considered medically necessary only when the specific air ambulance criteria are met; transports for indications other than those listed in the policy are not considered medically necessary. Similarly, Emergency Ground Ambulance Transportation is medically necessary only when the ground criteria are met. In practice, this means air medical transport should be reserved for situations where ground transport is impractical or would endanger life or health, the destination is the nearest capable acute care facility, and additional conditions such as an authority request or need for ALS/BLS during transport are present.

Coding and Billing Codes

Air Ambulance / RelatedHCPCS

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

Ground/Other Ambulance Supplies and MileageHCPCS

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

Ground/Other Ambulance ServicesHCPCS

A0420	Ambulance waiting time (ALS or BLS), one-half (1/2) hour increments
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
A0433	Advanced life support, level 2 (ALS 2)

1–10 of 12

1/2

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

Applicable HCPCS coding notes (New Jersey Medicaid notations)HCPCS

No codes listed

Applicable HCPCS codes with New Jersey fee-schedule notesHCPCS

A0140	HCPCS code A0140 noted as not on the State of New Jersey Medicaid Fee Schedule
A0426	HCPCS code A0426 — prior notation about NJ Medicaid fee schedule removed
A0430	HCPCS code A0430 — prior notation about NJ Medicaid fee schedule removed

Ground transport excessive time — example threshold

Example thresholdGround transport times described as excessive: 30–60 minutes or longer may justify air transport when delay may endanger life or health

Other examplesWhen weather or traffic make ground transport impractical, impossible, or overly time consuming

Access limitationsWhen the pickup point is inaccessible by ground ambulance

Destination requirementDestination must be the nearest acute care hospital that can meet the member's needs

Air transport distance efficiency note

Provider Actions, Prior Authorization, and Billing Guidance

Prior Authorization

Prior Authorization Required

Certain plans may require prior authorization for non-emergency ground ambulance transport. Refer to the member's federal, state, or contractual benefit plan requirements for specific prior authorization rules and processes.

Prior authorization may be plan-specific — verify with the member's benefit plan.
Air Ambulance: prior authorization is required for non-emergency air transport.

Note

When Air Medical Transport Is Indicated

Air medical transport should be used only when clinically indicated and aligned with nationally recognized guidance (NAEMSP/ACEP/AMPA). Use air transport when it meets one or more of the primary patient-centered goals: initiation/continuation of advanced or specialty care not available locally; expedited delivery to definitive care for time-sensitive intervention; or extraction/evacuation from inaccessible environments.

Air transport indicated when required specialty care is unavailable locally and timely access cannot be achieved by ground EMS (GEMS).

Definitions

Air Ambulance Service — definition

DefinitionProvision of emergency or non‑emergency medical transportation in an aircraft (fixed or rotary wing) certified by and operated in accord with Federal Aviation Administration requirements (N.J. Admin Code).

Aircraft typesIncludes both fixed‑wing and rotary‑wing aircraft

Regulatory noteOperated in accordance with FAA requirements per New Jersey Administrative Code (2025)

Medically Necessary — definition

Core definitionServices or supplies necessary to prevent, diagnose, correct, prevent worsening of, alleviate, or cure a physical or mental illness or condition; no equally effective, more conservative, or substantially less costly alternative exists

Appropriateness

Background and Evidence Summary

Air and ground ambulance services are required when no other safe transportation mode exists due to the severity or nature of the illness or injury and when transport mode is determined by appropriate authorities. Emergency air ambulance is medically necessary when immediate air transport is required because ground transport would endanger life or health (for example, when ground transport times are excessive—30–60 minutes or longer—or the pickup point is inaccessible), the destination is the nearest acute care hospital able to meet the member's needs, and either police/medical authorities request the service or ALS/BLS-level care is required during transport. Emergency ground ambulance is necessary when immediate transport to the nearest appropriate facility is required, delay would seriously endanger life or health, and ALS/BLS care is required during transport.

Revision History

2025-09-01definitions_updatedLatest

Updated definitions for 'Emergency Services' and 'Medically Necessary'.

2025-09-01coding_notation_added

Added notation that HCPCS code A0140 is not on the State of New Jersey Medicaid Fee Schedule and therefore may not be covered by the State of New Jersey Medicaid Program.

2025-09-01coding_notation_removed

Removed prior notation that HCPCS codes A0426 and A0430 are not on the State of New Jersey Medicaid Fee Schedule.

Policy Summary

PayerUnitedHealthcare

PolicyAmbulance Services (for New Jersey Only)

Policy CodePolicy CS003NJ.P

Change TypeUpdated definitionsNJ fee-schedule notation

Effective DateSeptember 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization when required for non-emergency air or ground ambulance transfers per plan and state rules.

SourceLink

On This Page

From National Expert Panel on Field Triage 2022

Distance efficiency findingRetrospective study (Kunte et al., 2021) found total interhospital transfer times were faster for air transportation only when traveling more than 40 miles

Study contextStudy reviewed 205 patient transfers (includes interhospital and scene transfers receiving tPA and/or thrombectomy)

Limitation notedAuthors cautioned results limited by retrospective design, small size, and selected patient population; recommended larger prospective studies

Air transport indicated for time-sensitive conditions (e.g., STEMI, acute stroke) when definitive care is not available locally.

Air transport indicated for rescue/extraction from remote or hazardous environments.

Note

Ground EMS Preferred When Appropriate

GEMS (ground EMS) is preferred when the patient's clinical needs and timely access to definitive care can be met by ground resources. Ground clinicians should be empowered to cancel an air response if continued air response would place crews at undue risk or would not meet one of the primary patient-centered goals for air transport.

Prefer GEMS if critical care expertise and timely transport to definitive care can be met by ground resources.
GEMS clinicians on scene may cancel air medical response when appropriate to avoid undue risk.

Note

Use of External Review Tools

UnitedHealthcare may use external, third-party utilization review tools (for example, InterQual®) to assist in administering benefits and determining coverage for ambulance transport requests. These tools support but do not replace the independent medical judgment of the treating provider.

InterQual® or similar criteria may be applied during review of transport requests.
Decisions also reference federal, state, or contractual benefit plan requirements.

Billing Rule

Non-Emergency Transport Routing

Non-emergency ambulance transport (ground or air) is covered only for facility-to-facility transfers when medically necessary and the destination is the closest network facility that can provide the required Covered Health Care Services, or when moving from an out-of-network hospital to the closest network hospital when Covered Health Care Services are required.

Covered facility-to-facility transfers include transfers to LTACs, inpatient rehabilitation, or other sub-acute facilities when the receiving facility can deliver the required services.
Transport for convenience or preference is not covered.

Documentation Required

Plan / Federal / State Precedence

When plan, federal, or state contractual terms conflict with this policy, the federal, state, or contractual requirements for the member's benefit plan govern. Providers must reference the member's applicable benefit plan terms when requesting authorization or making coverage determinations.

In the event of conflict, applicable federal, state, or contractual requirements prevail.
Verify plan-specific rules prior to transport and billing.

Documentation Required

Certificate of Medical Necessity and Documentation

Certificate of Medical Necessity (CMN) and other documentation: for scene transports, a receiving physician or transport program medical director may complete the CMN per AMPA guidance when applicable. Ensure all required clinical documentation is submitted with authorization requests and claims.

Receiving physician or transport program medical director may complete CMN on scene transports when allowed by regional policy.
Submit clinical justification and supporting documentation with prior authorization requests and claims to avoid denials.

Services, provider type, and setting must be consistent with the diagnosis and appropriate to the enrollee's specific medical needs

Pediatric considerationFor pediatric enrollees, services must be appropriate for age and health status and aid overall growth and functional capacity

Emergency Condition / Emergency Services — NJ definitions

Emergency conditionAn illness or injury of such magnitude and gravity as to constitute an imminent threat to life or limb or where there may be intractable pain (N.J. Admin Code).

Emergency servicesServices furnished by a qualified provider needed to evaluate or stabilize an emergency medical condition (N.J. Admin Code).

Superseding authorityFederal, state, or contractual definitions may supersede these definitions — check applicable plan terms

High‑risk field triage criteria (National Expert Panel 2022)

SourceNational Expert Panel on Field Triage (2022) high‑risk criteria covering anatomic injury, physiologic criteria, mechanism of injury, and EMS judgment

Anatomic (injury patterns)Penetrating injuries to head/neck/torso/proximal extremities; suspected spinal injury with new motor or sensory loss; chest wall instability/flail chest; suspected pelvic fracture; crushed/degloved/mangled/pulseless extremity; amputation proximal to wrist/ankle; active bleeding requiring tourniquet or wound packing

Physiologic (mental status/vitals)Unable to follow commands (motor GCS <6); RR <10 or >29; respiratory distress or need for respiratory support; room air SpO2 <90; age‑stratified SBP thresholds and HR > SBP rules for adults/elderly as specified

Mechanism & EMS judgmentHigh‑risk mechanisms (e.g., ejection, significant intrusion, falls >10 ft, pedestrian/bicycle impact) and EMS judgment factors should be used to identify patients for highest‑level trauma center triage; air medical services may be considered when feasible

Emergency Services; Medically Necessary — revision note

Update summaryDefinitions for ‘Emergency Services’ and ‘Medically Necessary’ were updated in the policy revision (09/01/2025)

Revision noteChanges are listed in Policy History/Revision Information and reflect updated clinical evidence and references

State applicabilityUpdates apply within the New Jersey policy version (CS003NJ.P)

2025-09-01supporting_information_updated

Updated Clinical Evidence and References sections to reflect the most current information.