CurrentWellpoint New Jersey MedicaidPolicy G-07036

Transportation Services: Ambulance and Non-Emergent Transport

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Reimbursement requirements for ambulance and non-emergency medical transportation to and from covered or contract-mandated services in New Jersey Medicaid, including coverage criteria, exclusions, billing modifiers, and transportation levels of care.

Policy Summary

PayerWellpoint New Jersey Medicaid

PolicyTransportation Services: Ambulance and Non-Emergent Transport

Policy CodePolicy G-07036

Change TypeMaterial coverage update

Effective DateMay 22, 2024

Next Review DateN/A

Key ActionBill transportation claims with the required origin and destination modifiers; claims without these modifiers may be denied.

SourceLink

POLICY UPDATE CHANGES

The policy removed ambulance base rate when no transportation is provided, such as treatment without transport, from the ambulance-only nonreimbursable services list.

Nearest facilityAmbulance destination standard

Modifiers requiredClaim billing requirement

Base rate + mileageAmbulance reimbursement

10Transportation modifiers

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CurrentWellpoint New Jersey MedicaidPolicy G-07036

Transportation Services: Ambulance and Non-Emergent Transport

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Sign up for wellpoint Policy G-07036 alerts

Get alerted when Policy G-07036 changes without checking for updates manually.

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Policy Summary

PayerWellpoint New Jersey Medicaid

PolicyTransportation Services: Ambulance and Non-Emergent Transport

Policy CodePolicy G-07036

Change TypeMaterial coverage update

Effective DateMay 22, 2024

Next Review DateN/A

Key ActionBill transportation claims with the required origin and destination modifiers; claims without these modifiers may be denied.

SourceLink

POLICY UPDATE CHANGES

The policy removed ambulance base rate when no transportation is provided, such as treatment without transport, from the ambulance-only nonreimbursable services list.

Nearest facilityAmbulance destination standard

Modifiers requiredClaim billing requirement

Base rate + mileageAmbulance reimbursement

10Transportation modifiers

13Nonreimbursable categories

Transportation Reimbursement Coverage Criteria

General transportation reimbursement

Covered when all of the following are met:

General eligibility

The transport is for a covered service or another service mandated by contract.
The service meets applicable authorization and medical necessity requirements for the procedure and diagnosis.
The claim uses compliant CPT, HCPCS, and/or revenue codes supported by the medical record or office notes.
The transportation claim includes required origin and destination modifiers, unless an applicable exception applies.

Ambulance services

Ambulance services are reimbursable when all applicable criteria are met; the following ambulance-specific services and circumstances are excluded:

Ambulance reimbursement

The ambulance transports the member to the nearest facility equipped to treat the member.
The ambulance base rate corresponds to the appropriate level of care provided.
Mileage is billed separately and does not exceed mileage to the nearest appropriate facility.
Services and supplies included in the ambulance base rate are not separately billed.
The transport is for medical care and another means of transportation could not be used without endangering the member's health.
Excluded ambulance circumstances
- The transport is not for a higher level of care when a lower level is more appropriate.

Non-emergency medical transport

NEMT is reimbursable when all applicable criteria are met; the following charges and circumstances are excluded:

NEMT reimbursement

The transport is to or from a covered service.
The billed mode of transportation is appropriate for the member's health status.
Any additional appropriately licensed medical personnel are needed for the member's health status.
Billed charges are limited to the medical transport base rate, mileage, unusual waiting time, and applicable parking or toll fees.
Excluded NEMT charges and circumstances
- The member is available for transport and is not a no-show.

Transportation Coding

Transportation origin, destination, and supplemental modifiersModifier

D	Diagnostic or therapeutic site or freestanding facility other than physician's office or hospital; origin and destination modifier
E	Residential, domiciliary, or custodial facility; origin and destination modifier
G	Hospital-based dialysis facility; origin and destination modifier
H	Hospital, inpatient or outpatient; origin and destination modifier
I	Site of transfer between two types of ambulance; origin and destination modifier
J	Nonhospital-based dialysis; origin and destination modifier
N	Skilled nursing facility, including swing bed; origin and destination modifier
P	Physician's office, including HMO nonhospital facility or clinic; origin and destination modifier
R	Private residence; origin and destination modifier
S	Scene of accident or acute event; origin and destination modifier

1–10 of 17

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Provider Billing and Compliance Actions

Prior Authorization

Confirm coverage, authorization, and medical necessity

Verify that the transportation service is covered under the member’s benefit plan and meets the authorization and medical necessity guidelines applicable to the procedure, diagnosis, and member’s state of residence.

Billing Rule

Submit required origin and destination modifiers

Bill transportation claims with the required origin and destination modifiers. Claims submitted without these modifiers may be denied.

Origin and destination modifiers are required for ambulance and NEMT claims.
An applicable modifier exception may apply, such as modifier QL when the member died after the ambulance was called.

Transportation Service Definitions

Advanced Life Support (ALS)

Service typeInvasive services

PersonnelPersonnel trained as emergency medical technicians, including intermediate or paramedic personnel

RequirementProvided in conjunction with applicable requirements

Air ambulance

VehicleAn equipped and staffed aircraft

Transport standardNecessary to rapidly transport a member to the nearest appropriate facility when ground ambulance transport could not safely accomplish or access the transport

Aircraft types

Policy Summary

PayerWellpoint New Jersey Medicaid

PolicyTransportation Services: Ambulance and Non-Emergent Transport

Policy CodePolicy G-07036

Change TypeMaterial coverage update

Effective DateMay 22, 2024

Next Review DateN/A

Key ActionBill transportation claims with the required origin and destination modifiers; claims without these modifiers may be denied.

SourceLink

On This Page

The claim does not bill both basic and advanced life support when ALS services are provided.

The claim does not separately bill services or items included in the ambulance base rate, including ambulance equipment, supplies, oxygen, intravenous drugs, and ambulance personnel services.

The claim does not include additional ambulance providers that responded but did not transport the member.

The transport is not for a member pronounced dead before the ground or air ambulance was contacted.

The claim does not include mileage beyond the nearest appropriate facility.

The claim does not include unloaded mileage, mileage for additional passengers, or mileage for an extra attendant for additional passengers.

The transport is not for the member's or caregiver's convenience and is not available free of charge.

The claim does not include night, weekend, or holiday call surcharges, vendor or supplier lodging or meals, vehicle maintenance, or gas.

Mileage is not billed when the transport service is denied or not covered.

Documentation Required

Use supported compliant codes and submission rules

Use industry-standard, compliant CPT, HCPCS, and/or revenue codes for the services performed, and ensure the codes are fully supported in the medical record and/or office notes. Follow the provider manual and applicable state and federal transportation submission requirements.

Incorrect coding or billing may result in claim rejection or denial, payment recovery or recoupment, or an adjustment to the appropriate services performed.

Denial Risk

Use the nearest appropriate treatment facility

For ambulance transport, take the member to the nearest facility equipped to treat the member. Do not bill mileage beyond the nearest appropriate facility; excessive mileage is nonreimbursable.

Denial Risk

Avoid excluded transportation charges

Do not bill transportation in nonreimbursable circumstances, including convenience transport, no-shows, free transportation, unloaded mileage, or mileage for additional passengers.

Additional nonreimbursable charges include vendor or supplier lodging and meals, vehicle maintenance, gas, and additional rates for night, weekend, or holiday calls.

Denial Risk

Bill only the appropriate ambulance level and included services

Bill only the ambulance level of care appropriate to the member’s needs and do not separately bill services or supplies included in the ambulance base rate. Do not bill both BLS and ALS when ALS services are provided, or bill responding ambulance providers that do not transport the member.

The ambulance base rate includes equipment and supplies, oxygen, IV drugs, and ambulance personnel services.
Mileage is separately reimbursed from the ambulance base rate.

Rotary-wing or fixed-wing

Ambulance services

ServiceMedically necessary transport of a member

Personnel and destinationTransport by medically skilled personnel to the nearest appropriate facility equipped to provide care for the member's injury or illness

ClassificationsServices are categorized as Basic Life Support (BLS) or Advanced Life Support (ALS), and as emergency or non-emergency

Basic Life Support (BLS)

Service typeNoninvasive services

PersonnelPersonnel trained as basic emergency medical technicians (EMTs)

RequirementProvided in accordance with applicable state laws

Emergency ambulance transportation

Transport typeUrgent transport

Clinical circumstanceA sudden, unexpected acute illness or injury requiring immediate medical or surgical care

Urgency standardIf not immediately treated, the condition could result in death or permanent impairment to the member's health

Ground ambulance

Vehicle typeAn equipped and staffed vehicle

Permitted vehicleLand or water vehicle

Transport positionDesigned to transport a member in the supine position

Nonemergency ambulance transportation

SchedulingScheduled or unscheduled transport

Personnel requirementThe member requires attention by EMT-trained personnel while in transit

Service typeAmbulance transportation that is not emergency transportation

Non-Emergency Medical Transport Services (NEMT)

PersonnelTransport by non-medically skilled personnel, such as laypersons

PurposeTransport for a member to receive covered services

Transport modesAmbulette or medi-van, wheelchair van, invalid coach, taxicab, minibus, and public transportation