ModifiedUnitedHealthcarePolicy 2025R0123I

Ambulance Transportation Reimbursement Policy — UnitedHealthcare Community Plan

Governs UnitedHealthcare Community Plan Medicaid reimbursement for ambulance transportation services, including eligible suppliers, modifier usage, bundled services, ALS2 reporting, ESRD adjustments, and state exceptions; affects providers billing on CMS-1500 or electronic equivalent.

Policy Summary

PayerUnitedHealthcare

PolicyAmbulance Transportation Reimbursement Policy — UnitedHealthcare Community Plan

Policy CodePolicy 2025R0123I

Change TypeMaterial updates and state attachment revisions

Effective Date

Next Review Date

Key ActionDo not bill ambulance transport codes for physician services provided during transport; report appropriate non-ambulance CPT codes (e.g., 92950) instead.

SourceLink

POLICY UPDATE CHANGES

Ambulance Transportation During an Inpatient Stay section added.

Q&A entry clarifying that physicians riding in ambulances should bill non-ambulance service codes (e.g., CPT 92950 for CPR).

Multiple state exception sections and attachments updated across several dates (e.g., North Carolina updated 6/16/2024; many states updated 5/28/2025).

Q&A addedpolicy clarification

A0021–A0999reimbursable HCPCS range

Same daybundled services

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Coverage and Reimbursement Criteria

inv-01: Coverage criteria — reimbursement conditioned on supplier type, proper modifier usage, bundled-service rules, ALS level, ESRD adjustments, state exceptions

UnitedHealthcare Community Plan reimbursement is conditioned on supplier eligibility, correct origin/destination modifier use, bundled-service rules, ALS2 documentation, ESRD adjustments, and inpatient date-overlap exclusions.

ALL of the following

ALL of the following
- Only an Ambulance Supplier may be reimbursed for HCPCS ambulance transportation codes A0021 and A0225-A0999.
  UnitedHealthcare Community Plan will not reimburse non-Ambulance Suppliers for rendering ambulance services.
- Other provider specialties (e.g., emergency room physicians) must report CPT and/or HCPCS codes that accurately describe services and will not be reimbursed for ambulance codes.
ALL of the following
- A valid two-character origin/destination ambulance modifier must be reported with each ambulance trip; the first position identifies origin and the second identifies destination.2-digit
  Codes on the Ambulance Transportation Codes list will be reimbursed only when reported with a two-digit ambulance modifier on the Ambulance Modifiers list.
- If 'X' is used within the modifier pair it must appear in the second position; if 'X' is the first digit the claim will be denied.
  Ambulance transportation services reported without a valid two-digit ambulance modifier will be denied.
ALL of the following
- Services including oxygen, drugs, extra attendants, supplies, EKG, night differential and other listed Ambulance Bundled Codes are considered part of the ambulance service and are not separately reimbursable when provided by the Same Ambulance Supplier on the same date of service as a transportation code.same day
  Same Ambulance Supplier = suppliers of the same specialty reporting the same federal tax identification number.
ALL of the following
- Reimbursement for ALS2 requires meeting CMS ALS2 criteria: either at least three separate administrations of one or more medications by IV push/bolus or continuous infusion (excluding crystalloid fluids) OR provision of at least one specified ALS2 procedure (e.g., manual defibrillation, endotracheal intubation, central venous line, cardiac pacing, chest decompression, surgical airway, intraosseous line).>= 3 IV medication administrations or >= 1 ALS2 procedure
  Reimbursement is based on level of service provided, not on the vehicle used.
ALL of the following
- Apply a 23% reimbursement reduction to nonemergency BLS code A0428 and associated mileage A0425 for transports to/from renal dialysis when billed with a 'G' (hospital-based ESRD) or 'J' (freestanding ESRD facility) in either origin or destination modifier position.23% reduction
ALL of the following
- Ambulance transports to/from an originating facility to another facility for diagnostic tests or specialty treatment (reported with modifiers HH, DH or HD) will not be reimbursed if the dates of service overlap with an inpatient stay; the admission and discharge dates are excluded from the overlap calculation.
ALL of the following
- Numerous state-specific exceptions modify code coverage, modifier lists, ESRD reduction applicability, and inpatient overlap rules as listed in the State Exceptions section and attachments.
  See State Exceptions and attachments for details.

ALL of the following

Reimbursement is conditioned on accurate claims submission on CMS-1500 or electronic equivalent and may vary by state and system-level rules.
Providers are responsible for accurate claims submission.

inv-02: Coverage criteria and notes — specific non-reimbursable situations and Q&A clarifications

Coverage stance and specific non-reimbursable situations and clarifications from the Q&A.

ANY of the following

Ambulance transport from one originating facility to another facility and back to the originating facility will not be reimbursed if the date(s) of service overlap with an inpatient stay, excluding the admit and discharge dates.
This clarification was added to the policy (see history).
If a physician rides in the ambulance and provides services such as CPR while enroute, the physician should report appropriate non-ambulance CPT codes (for example, CPT 92950 for CPR) rather than ambulance transport codes.
Physician-provided services during transport are reported separately from ambulance transport codes.
Attachments and resources including Ambulance Transportation Codes, Ambulance Bundled Codes, and Ambulance Modifiers are provided; state-specific modifier lists and numerous state exception updates are included in attachments and the Resources/History section.
See attachments and Resources section for updated lists and state exception details (multiple updates 2023-2025).

Codes, Modifiers, and Coding Rules

Ambulance transportation and related codesHCPCSCovered

A0021, A0225-A0999	HCPCS ambulance transportation codes reimbursable only when reported by Ambulance Suppliers
A0428, A0425	Nonemergency BLS transport and associated mileage subject to ESRD reduction when to/from dialysis

Example non-ambulance service codesCPT

92950

Cardiopulmonary resuscitation (example non-ambulance code to be reported by physician)

ALS2 medication administrations threshold — inv-06

ALS2 medication administrations thresholdAt least three separate IV administrations (intravenous push/bolus or continuous infusion) of one or more medications, excluding crystalloid fluids

Alternate ALS2 criterionProvision of at least one listed ALS2 procedure (e.g., manual defibrillation/cardioversion, endotracheal intubation, central venous line, cardiac pacing, chest decompression, surgical airway, intraosseous line)

Reimbursement basisReimbursement is based on level of service provided (ALS2) and not on the vehicle used

Policy attachment update frequency — inv-07

Attachment update cadenceMultiple updates to Attachments and Ambulance Bundled Codes between 2023–2025 (examples: Ambulance Bundled Codes updated 3/30/2025, 1/1/2025, 6/29/2025)

Provider Billing Guidance and Actions

Note

Application and general note

This reimbursement policy applies to UnitedHealthcare Community Plan Medicaid products and to services reported using the CMS-1500 (1500 Health Insurance Claim Form) or its electronic equivalent. It applies to all products and to all network and non-network physicians and other qualified health care professionals, including non-network authorized and percent-of-charge contract physicians and other qualified health care professionals. You are responsible for submission of accurate claims; reimbursement is based on the code(s) that correctly describe the services provided. UnitedHealthcare Community Plan uses CPT, CMS and other coding guidelines. References to CPT or other sources are definitional only and do not guarantee reimbursement.

Applies to UnitedHealthcare Community Plan Medicaid products
Applies to services reported on CMS-1500 or electronic equivalent
Applies to all network and non-network physicians and other qualified health care professionals
Providers are responsible for accurate claim submission and appropriate code selection

Denial Risk

Ambulance transportation during inpatient stay

Definitions and Terminology

Same Ambulance Supplier — inv-11

DefinitionAmbulance Suppliers of the same specialty reporting the same Federal Tax Identification number (TIN)

ContextUsed to determine when services or listed Ambulance Bundled Codes provided by the same supplier are not separately reimbursable on the same date of service

Reference in policyTerm appears in Overview and Definitions sections to inform bundled-service and reimbursement rules

ALS2 — Advanced Life Support, Level 2 definition — inv-12

DefinitionAdvanced Life Support, Level 2 (ALS2): transportation by ground ambulance and the provision of medically necessary supplies and services including either (1) at least three separate administrations of one or more medications by IV push/bolus or continuous infusion (excluding crystalloid fluids) or (2) provision of at least one specified ALS2 procedure (e.g., defibrillation, intubation, central venous line, cardiac pacing, chest decompression, surgical airway, intraosseous line)