CurrentUnitedHealthcarePolicy CSNC.MP.001.09

Ambulance Services (for North Carolina Only)

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Defines UnitedHealthcare Community Plan reimbursement policy for ambulance services applicable only to North Carolina members; aligns coverage criteria to North Carolina Medicaid Clinical Coverage Policy.

Policy Summary

PayerUnitedHealthcare

PolicyAmbulance Services (for North Carolina Only)

Policy CodePolicy CSNC.MP.001.09

Change TypeMaterial updates and clarifications

Effective DateAug 1, 2026

Last ReviewAug 1, 2026

Next Review Date

Key ActionMake member medical records (history, exam, and diagnostic results) available to support medical necessity when requested.

SourceLink

POLICY UPDATE CHANGES

Medical Records Documentation Used for Reviews: added detailed requirements about documentation supporting medical necessity.

Applicable Codes: added modifier QL.

Policy applies only to the state of North Carolina.

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CurrentUnitedHealthcarePolicy CSNC.MP.001.09

Ambulance Services (for North Carolina Only)

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Policy Summary

PayerUnitedHealthcare

PolicyAmbulance Services (for North Carolina Only)

Policy CodePolicy CSNC.MP.001.09

Change TypeMaterial updates and clarifications

Effective DateAug 1, 2026

Last ReviewAug 1, 2026

Next Review Date

Key ActionMake member medical records (history, exam, and diagnostic results) available to support medical necessity when requested.

SourceLink

POLICY UPDATE CHANGES

Medical Records Documentation Used for Reviews: added detailed requirements about documentation supporting medical necessity.

Applicable Codes: added modifier QL.

Policy applies only to the state of North Carolina.

Coverage and Administrative Requirements

Coverage criteria and administrative requirements

Coverage is determined by applicable federal, state, or contractual requirements; for clinical coverage criteria, see the referenced North Carolina Medicaid Clinical Coverage Policy.

Coverage and payment decisions are governed by applicable federal, state, or contractual requirements; when conflicts exist, those requirements govern.

For clinical coverage criteria, refer to the North Carolina Medicaid (Division of Health Benefits) Clinical Coverage Policy, Ambulance:15 (Ambulance Services).

Medical records documentation may be required to assess whether the member meets clinical criteria; documentation requests do not guarantee coverage.

The patient’s medical record must contain documentation that fully supports medical necessity, including but not limited to relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.

Documentation supporting medical necessity must be legible, maintained in the patient’s medical record, and made available upon request.

Representative Codes and Modifiers

Representative ambulance HCPCS and modifier codesHCPCS | Modifier

A0225	Ambulance service, neonatal transport, base rate, emergency transport, one way
A0380	Ambulance service, neonatal transport, base rate, emergency transport, one way BLS mileage (per mile)
A0382	BLS routine disposable supplies
A0384	BLS specialized service disposable supplies; defibrillation (used by ALS ambulances and BLS)
A0390	Ambulances in jurisdictions where defibrillation is permitted in BLS ambulances; ALS mileage (per mile)
A0392	ALS specialized service disposable supplies; defibrillation (to be used only in jurisdictions where defibrillation is permitted)
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

1–10 of 30

1/3

Ambulance claim modifiers required

Claim modifier sequenceClaims must be billed with two modifiers: the first modifier indicates place of origin and the second modifier indicates destination.

Modifier purposeFirst modifier = place of origin (where transport begins).

Second modifier purposeSecond modifier = destination (where transport ends).

Billing enforcementBoth modifiers are required on ambulance claims to indicate origin and destination per policy guidance.

Authorization and Documentation Requirements

Prior Authorization

Refer to NC Medicaid Clinical Coverage Policy for prior authorization/coverage

For clinical coverage criteria and prior authorization guidance, refer to the North Carolina Medicaid (Division of Health Benefits) Clinical Coverage Policy, Ambulance, 15: Ambulance Services. When deciding coverage, reference federal, state, or contractual requirements; those requirements govern in the event of a conflict.

Documentation Required

Maintain complete, legible medical records to support medical necessity

Medical records documentation may be requested to determine whether the member meets clinical criteria; documentation must fully support medical necessity and does not guarantee coverage. Records must include relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures, be legible, maintained in the patient's medical record, and made available upon request.

Modifiers and Code Definitions

Modifiers indicating origin and destination for ambulance claims

GHospital-based ESRD facility (origin/destination).

HHospital (origin/destination).

RResidence (origin/destination).

SScene of accident or acute event (origin/destination).

XIntermediate stop at physician's office on way to the hospital — can only be used as a destination code in the second modifier position.

Examples: other codesI=Site of transfer (e.g., airport or helicopter pad); J=Freestanding ESRD facility; N=Skilled nursing facility; P=Physician's office; D/E used for diagnostic/therapeutic or residential facilities.