CurrentUnitedHealthcarePolicy CS003OH.D

Ambulance Services Oh Cs

Defines UnitedHealthcare's policy for coverage of ground and air ambulance services for members in Ohio, referencing Ohio Administrative Code Rules 5160-15-23 (ground) and 5160-15-24 (air) for medical necessity criteria. Includes applicable HCPCS/HCFA codes, ambulance modifiers, revenue codes, and billing notes; applies only to Ohio.

Policy Summary

PayerUnitedHealthcare

PolicyAmbulance Services Oh Cs

Policy CodePolicy CS003OH.D

Change TypeRoutine review; no change

Effective DateAug 1, 2025

Next Review Date

Key ActionProvider must document that ground or air ambulance transport meets Ohio Administrative Code Rule 5160-15-23 (ground) or 5160-15-24 (air) medical necessity criteria; benefit coverage determined by federal, state, or contractual requirements.

SourceLink

POLICY UPDATE CHANGES

Routine review; no change to coverage guidelines.

OhioJurisdiction

Ground & AirTransport Types Covered

OAC 5160-15-23/24Medical Necessity Source

Coverage Summary

Overview: This policy (CS003OH.D) defines UnitedHealthcare's coverage approach for ground and air ambulance services for the state of Ohio only. Coverage and medical necessity are determined per Ohio Administrative Code Rule 5160-15-23 for ground ambulance and Rule 5160-15-24 for air ambulance. The policy effective date is August 1, 2025 and last review date is August 1, 2025. Coverage stance: mixed — services are covered when they meet the OAC medical necessity criteria and remain subject to federal, state, or contractual requirements.

Medical‑Necessity Criteria

Medically Necessary Ambulance Transport (Ground and Air) per Ohio OAC

Ambulance services are considered medically necessary in certain circumstances per Ohio Administrative Code; coverage follows OAC rule-specific criteria:

OAC-based medical necessity for ambulance transport

State application: This policy applies only to the state of Ohio; requests for services stated as unproven or with coverage/quantity limits will be evaluated under OAC 5160-101.
Reference: policy applies to Ohio and uses OAC 5160-101 for certain reviews.
Ground ambulance rule: Medical necessity for ground ambulance services must meet Ohio Administrative Code Rule 5160-15-23 (Transportation: services from an eligible provider: ground ambulance services).
Operational note: document member eligibility and service location as within Ohio per OAC 5160-15-23.
Air ambulance rule: Medical necessity for emergency air ambulance services must meet Ohio Administrative Code Rule 5160-15-24 (Transportation: services from an eligible provider: air ambulance services).
Operational note: emergency air transports are governed by OAC 5160-15-24; nonemergency air transports are addressed by applicable code listings and state rules.

Coding and billing notes: Ambulance claims must be billed with two modifiers indicating place of origin and destination; modifier X may only be used as a destination code in the second modifier position.

Include applicable HCPCS and revenue codes per policy; see policy Applicable Codes section for code lists.

Medical Review Requirement

Certain services require medical review:

Services requiring medical review: Extra ambulance attendant (HCPCS A0424) requires medical review prior to payment.

HCPCS A0424 is designated in the policy as requiring medical review.

Other medical review pathways: Other services or claims that do not clearly meet OAC medical necessity criteria may be evaluated under Ohio Administrative Code 5160-101.

OAC 5160-101 is used to evaluate requests for unproven services or services with coverage/quantity limits.

Coding

Air Ambulance HCPCSHCPCSCovered

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 HCPCSHCPCSCovered

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
A0420	Ambulance waiting time (ALS or BLS), one-half (1/2) hour increments

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Ambulance 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 Modifiers (Place of Origin/Destination)Modifier

D	Diagnostic or therapeutic site other than P or H 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 modes of ambulance transport
J	Freestanding ESRD facility
N	Skilled nursing facility
P	Physician's office
QL	Patient pronounced dead after ambulance called (use as applicable)
R	Residence

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Billing note: Ambulance claims must be billed with two modifiers indicating the place of origin (first modifier) and the place of destination (second modifier). Modifier X (intermediate stop at physician's office) is only permitted when used as the second modifier (destination) position.

Provider Actions & Billing

Documentation Required

Use Ohio OAC medical necessity criteria

Providers must document that ground or air ambulance transports meet the Ohio Administrative Code medical necessity criteria: OAC 5160-15-23 for ground ambulance services and OAC 5160-15-24 for air ambulance services. Benefit coverage is determined by federal, state (OAC), or contractual requirements; document how the transport satisfies the cited OAC rule(s).

Ground ambulance medical necessity: OAC 5160-15-23 (refer to rule text).
Air ambulance medical necessity: OAC 5160-15-24 (refer to rule text).

Billing Rule

Report ambulance modifiers

Ambulance claims must be billed with two modifiers indicating place of origin and destination. Report the appropriate origin and destination modifier on claims; note that modifier X (intermediate stop at physician's office on way to the hospital) is a destination code only and may be used only in the second modifier position.

Bill claims with two ambulance place-of-origin/destination modifiers (first modifier = origin, second modifier = destination).
Modifier X denotes an intermediate stop at a physician's office and can only be used as a destination code in the second modifier position.

Documentation Required

Medical review for extra attendant

HCPCS code A0424 (extra ambulance attendant, ground or air) requires medical review prior to payment. Include documentation supporting the medical necessity of the extra attendant when submitting claims to facilitate review.

Affected HCPCS: A0424

Denial Risk

Coverage contingent on OAC and contract

Coverage is contingent upon meeting Ohio Administrative Code medical necessity rules and any applicable federal, state, or contractual requirements. Claims that do not meet OAC 5160-15-23 (ground) or OAC 5160-15-24 (air), or that conflict with federal/state/contract terms, may be denied.

Transports failing to meet the referenced OAC criteria may be denied.
Federal, state, or contract rules override policy; check applicable requirements before claiming coverage.

Background

Background: This Medical Policy applies only to the state of Ohio and defers medical necessity determinations for ambulance transport to the Ohio Administrative Code. For ground ambulance services, clinical medical necessity criteria are defined in Ohio Administrative Code Rule 5160-15-23; for emergency air ambulance services, criteria are in Rule 5160-15-24. UnitedHealthcare uses InterQual for primary medical/surgical criteria when applicable. This policy is informational and coverage determinations remain subject to applicable federal, state (OAC), or contractual requirements and may require medical review for certain services (for example, HCPCS A0424 extra ambulance attendant).

Definitions

OAC Rule Definitions (per policy)