CurrentUnitedHealthcarePolicy CS003NE.R

Ambulance Services (for Nebraska Only)

State-specific UnitedHealthcare medical policy governing ambulance services for members in Nebraska; refers to Nebraska Department of Health and Human Services Code 471-4 for medical necessity clinical criteria and provides applicable billing codes and modifiers for ambulance and air ambulance services. Applies only to Nebraska.

Policy Summary

PayerUnitedHealthcare

PolicyAmbulance Services (for Nebraska Only)

Policy CodePolicy CS003NE.R

Change TypeRoutine review; no change to coverage guidelines

Effective DateJul 1, 2025

Next Review Date

Key ActionProviders must refer to and document compliance with Nebraska Department of Health and Human Services Title 471, Chapter 4 ambulance services medical necessity criteria when requesting coverage; medical review may be required.

POLICY UPDATE CHANGES

Routine review; no change to coverage guidelines.

State-specificGeographic Scope

Nebraska DHHS 471-4Clinical Criteria Source

MultipleCodes Listed

Coverage Summary

State-specific UnitedHealthcare medical policy for ambulance services in Nebraska; defers clinical medical necessity determinations to the Nebraska Department of Health and Human Services, Code 471-4. The policy lists applicable HCPCS and revenue codes and billing conventions for ambulance and air ambulance services. Effective Date: July 1, 2025; Last Review: July 1, 2025.

Medical-Necessity Criteria

Medical Necessity

Coverage follows Nebraska Department of Health and Human Services, Code 471-4: Ambulance Services. Refer to that regulation for medical necessity clinical coverage criteria.

ALL of the following

Policy applies only to services in the State of Nebraska.
Medical necessity clinical coverage criteria: see Nebraska DHHS Title 471, Chapter 4 (Ambulance Services).

Applicable Codes

Air Ambulance CPT/HCPCSHCPCS

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 CPT/HCPCSHCPCS

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 (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 (exception: QL billed in place of origin/destination combination).
R	Residence.

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The policy lists applicable HCPCS and revenue codes and describes modifier usage and billing conventions: ambulance claims are billed with two modifiers where the first indicates the origin and the second indicates the destination. QL is used in place of the origin/destination combination when the patient is pronounced dead after the ambulance is called, and X is an intermediate stop at a physician's office that may only be used as a destination code in the second modifier position.

Provider Actions & Billing Rules

Documentation Required

Follow Nebraska DHHS Medical Necessity Criteria

Providers must refer to and document compliance with Nebraska Department of Health and Human Services Title 471, Chapter 4 (Ambulance Services) when requesting coverage. Medical review may be required to determine medical necessity per the referenced Nebraska DHHS regulation and this policy.

Medical review may be required.

Billing Rule

Ambulance Modifier Reporting

Ambulance claims must be billed with two modifiers: the first indicates the origin and the second indicates the destination. The QL modifier is used in place of the origin/destination combination when the patient is pronounced dead after the ambulance is called. Modifier X may only be used as a destination code in the second modifier position.

Billing Rule

Extra Attendant Requires Medical Review

Report extra ambulance attendant services with HCPCS code A0424. Use of A0424 requires medical review under this policy.

A0424

Definitions & Background

This policy applies only in Nebraska and defers medical necessity clinical coverage criteria to Nebraska DHHS Title 471, Chapter 4 (Ambulance Services). It provides lists of applicable ambulance and air ambulance HCPCS and revenue codes and describes modifier usage and billing conventions for reporting origin and destination modifiers on claims.

Term	Definition
{"text":"QL modifier","status":""},{"text":"Used in place of the origin/destination combination when patient pronounced dead after ambulance called.","status":"covered"}
{"text":"Modifier X","status":""},{"text":"Intermediate stop at physician's office on way to the hospital; can only be used as a destination code in the second modifier position.","status":"covered"}