CurrentUnitedHealthcarePolicy 2025R5018A

Ambulance transportation modifiers and reimbursement

Reimbursement rules for ambulance transportation services billed on UB04 (or electronic equivalent) for UnitedHealthcare Commercial and Individual Exchange plans, including required two-character origin/destination modifiers and institutional reporting of QM/QN.

Policy Summary

PayerUnitedHealthcare

PolicyAmbulance transportation modifiers and reimbursement

Policy CodePolicy 2025R5018A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionReport ambulance HCPCS with a valid two-digit origin/destination modifier; institutional providers must also append QM or QN.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

A0425–A0436ambulance HCPCS codes referenced

0540/0545required revenue codes

two-digitrequired ambulance origin/destination modifier

QM/QNinstitutional provider modifier

Ambulance Reimbursement Criteria

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Ambulance reimbursement criteria

Reimbursement conditions for ambulance transportation codes:

Ambulance transportation codes will be reimbursed only when reported with a valid two-digit ambulance modifier (single-character origin in first position + single-character destination in second position).

If an ambulance transportation claim is submitted without a valid two-digit modifier, the claim will be denied.

When modifier 'X' (intermediate stop at physician's office) is used, it must be in the second position only; if 'X' is the first digit of the two-digit modifier, the code will be denied.

Institutional-based providers must append QM (arranged) or QN (direct) with the HCPCS code in addition to the two-digit origin/destination modifier.

Ambulance service and mileage must be reported on separate lines with the same date of service on the same claim; ambulance service should be reported with one unit and mileage units should equal the loaded miles billed; use revenue code 0540 or 0545 when appropriate.

Renal dialysis transports

Non-emergency BLS renal dialysis transports must be reported with HCPCS code A0428.
Renal dialysis transports must include ESRD origin/destination modifier 'G' (hospital-based ESRD) or 'J' (freestanding ESRD) in the two-digit modifier as appropriate.

Ambulance Codes, Modifiers, and Units

Covered HCPCS CodesHCPCSCovered

A0425	Ground mileage, per statute mile
A0426	Advanced life support, non-emergency transport, level 1
A0427	Advanced life support, emergency transport, level 2
A0428	Basic life support, non-emergency transport
A0429	Basic life support, emergency transport
A0430	Advanced life support, level 1 (ALS1) — non-emergency?
A0431	Advanced life support, level 2 (ALS2) — non-emergency?
A0432	Specialty care transport
A0433	Extrication, per transport
A0434	Fixed wing air ambulance transport, per mile

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Required Two‑Character Origin/Destination ModifiersModifierCovered

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
R	Residence
S	Scene of accident or acute event

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Institutional ModifiersModifierCovered

QM	Ambulance services provided under arrangement by the provider of services (institutional-based)
QN	Ambulance services provided directly by the institutional provider

Units for ambulance service and mileage

Service unitsReport the ambulance service with one unit.

Mileage unitsReport mileage as the loaded number of miles billed; each mile is one unit.

Prior Authorization and Billing Requirements

Billing Rule

Prior authorization and billing requirements

Report each ambulance transportation HCPCS code with a valid two-character origin/destination modifier (single alpha character for origin in first position and destination in second). If the two-character modifier is missing or invalid, the ambulance transportation claim will be denied. When the 'X' intermediate-stop code is used it must be in the second position only; if 'X' is the first digit the claim will be denied. Institutional-based providers must also append QM (arranged) or QN (direct) with the HCPCS code. Report ambulance service and mileage on separate lines with the same DOS and same claim, using revenue code 0540 or 0545 as appropriate; ambulance service should be one unit and mileage units should equal loaded miles billed.

Use a two-character origin+destination modifier (e.g., RH) with each ambulance HCPCS; single-character alpha codes designate origins/destinations (D, E, G, H, I, J, N, P, R, S, X).
Transports reported without a valid two-digit modifier will be denied.
'X' (intermediate stop at physician's office) must be the second character; if 'X' is first the code will be denied.
Institutional providers must report QM (arranged) or QN (direct) appended to the HCPCS code.
Report service and mileage on separate lines same DOS/same claim; use revenue code 0540 or 0545 when appropriate; report one unit for service and mileage units equal loaded miles billed.

Provider / Supplier Definitions

Provider / supplier

Provider (hospital-based)'Provider' refers to a hospital-based ambulance provider; institutional-based providers must append QM (arranged) or QN (direct) with the HCPCS code.

Supplier (non-institutional)'Supplier' refers to any ambulance service that is not institutionally based.

Modifier requirement for institutional providersInstitutional-based providers must report QM for services provided under arrangement or QN for services provided directly in addition to the two-digit origin/destination modifier.