Ambulance Guidelines

Policy No: 121
Originally Created: 03/01/2015
Section: Administrative
Last Reviewed: 03/01/2024
Last Revised: 03/01/2024
Approved: 03/14/2024
Effective: 04/01/2024
Policy Applies to: Group and Individual & Medicare Advantage

The policy applies to ground and air ambulance providers, including facilities providing and billing for transport services.

Air Ambulance
There are two categories of air ambulance services: fixed wing (airplane) and rotary wing (helicopter) aircraft. Air ambulance must meet the vehicle requirements as outlined in the definition of "The Vehicle" below.

1. Fixed Wing Air Ambulance (FW) - Fixed wing air ambulance is furnished when the member's medical condition is such that transport by ground ambulance, in whole or in part, is not appropriate. Generally, transport by fixed wing air ambulance may be necessary because the member's condition requires rapid transport to a treatment facility, and either great distances or other obstacles, e.g., heavy traffic, preclude such rapid delivery to the nearest appropriate facility. Transport by fixed wing air ambulance may also be necessary because the beneficiary is inaccessible by a ground or water ambulance vehicle.
2. Rotary Wing Air Ambulance (RW) - Rotary wing air ambulance is furnished when the member's medical condition is such that transport by ground ambulance, in whole or in part, is not appropriate. Generally, transport by rotary wing air ambulance may be necessary because the beneficiary's condition requires rapid transport to a treatment facility, and either great distances or other obstacles, e.g., heavy traffic, preclude such rapid delivery to the nearest appropriate facility. Transport by rotary wing air ambulance may also be necessary because the beneficiary is inaccessible by a ground or water ambulance vehicle.

Ground Ambulance
Ground ambulance refers to both land and water transportation and must meet the vehicle requirements as outlined in the definitions of "The Vehicle" below.

Specialty Care Transport (SCT)
Interfacility transportation of a critically ill or injured beneficiary that is necessary because the beneficiary’s condition requires ongoing care furnished by one or more professionals in an appropriate specialty (such as emergency or critical care nursing, emergency medicine, respiratory or cardiovascular care or a paramedic with additional training) and must meet the vehicle requirements as outlined below.

The Vehicle
Any vehicle designed and equipped to respond to medical emergencies and, in nonemergency situations, is capable of transporting members with acute medical conditions. Generally, the vehicle must comply with State or local laws governing the licensing and certification of an emergency medical transportation vehicle; and contain a stretcher, linens, emergency medical supplies, oxygen equipment, and other lifesaving emergency medical equipment and be equipped with emergency warning lights, sirens, and telecommunications equipment as required by State or local law; and include, at a minimum, one 2-way voice radio or wireless telephone.

Basic Life Support (BLS) ambulances must be staffed by at least two people, who meet the requirements of state and local laws where the services are being furnished and where, at least one of whom (1) must be certified at a minimum as an emergency medical technician- basic (EMT-basic) by the state or local authority where the services are being furnished and (2) be legally authorized to operate all lifesaving and life-sustaining equipment on board the vehicle.

Advanced Life Support (ALS) vehicles must be staffed by at least two people, who meet the requirements of state and local laws where the services are being furnished and where, at least one of whom must (1) meet the vehicle staff requirements above for BLS vehicles and (2) be certified as an EMT-Intermediate or an EMT-Paramedic by the state or local authority where the services are being furnished to perform one or more ALS services.

Our health plan adheres to following the guidelines on reimbursement of Ground Ambulance and Air Ambulance services:

Reimbursement is not allowed when the ambulance line item service date falls within the admission and discharge dates on a hospital inpatient claim with the following exceptions:

• Reimbursement will be allowed when the ambulance line item service date is the same as the admission or discharge date.
• Reimbursement is allowed for transportation, including transportation by ambulance, to and from another hospital or freestanding facility to receive specialized diagnostic or therapeutic services not available at the facility where the patient is an inpatient. If the ambulance is owned by the hospital then it should not be billed separately.
• When the beneficiary is an inpatient of a long-term care facility (LTCH), inpatient psychiatric facility (IPF) or inpatient rehabilitation facility (IRF) and is transported via ambulance to an acute care hospital to receive specialized services, reimbursement will be allowed if the presence of occurrence span code 74 (non-covered level of care) and the associated occurrence span code from and through dates is plus one day. The claim will be denied if the ambulance line item service date falls outside the occurrence span code 74 from and through dates plus one day.

• Reimbursement is allowed for SCT, however the reimbursement for SCT includes the provision of medically necessary supplies and services at a level of service beyond the scope of an EMT-Paramedic, these items/services will not be reimbursed separately.

Host Local Air Ambulance

Effective for date of service 04/19/2015 and after, air ambulance claims must be submitted to the plan based on the point of pick-up (zip code). Claims that are either missing the pick-up zip code, or if the pick-up zip code is not in our service area, will be denied back to the provider.

Services Included in Ambulance Transportation

Per CMS services including, but not limited to oxygen, drugs, extra attendants, supplies, EKG, and night differential are not paid separately when reported as part of an ambulance transportation service.

Ambulance Modifiers

Reimbursement will only be made when billed with the two-digit ambulance modifier*. Any claim billed without the two-digit ambulance modifier will be denied.

Exception*: A0998 - Ambulance response and treatment, no transport - Ambulance service modifiers are not required. The submission of an ambulance modifier with this code may result in a denial. (A0998 is reimbursable for Commercial and Medicare Advantage)

Each ambulance modifier consists of two digits as follows:

1. A single digit alpha character identifying the origin of the transport in the first position; and

2. A single digit alpha character identifying the destination of the transport in the second position. (e.g., SH = scene of accident or acute event to hospital)

Below is a list of the modifiers eligible for reimbursement. Any claim billed without the two-digit ambulance modifier or modifier QL will be denied.

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 - Free standing ESRD facility
N - SNF
P - Physician's office
R - Residence
S - Scene of accident or acute event
X - Intermediate stop at physician's office on way to hospital (destination code only)
QL - Patient pronounced dead after ambulance called

The following modifiers are considered secondary modifiers – do not bill in the first position:

GM - Multiple patients on one ambulance trip.
QM - Ambulance service provided under arrangement by a provider of services
QN - Ambulance service furnished directly by a provider of services

Transportation Indicators

One of the transportation indicators below may be included on the claim to indicate why it was necessary for the patient to be transported in a particular manner or circumstance.

The transportation indicator should be placed in the "narrative" field on the claim.

• Air and Ground

  • Transportation Indicator "C1": Transportation indicator "C1" indicates an inter-facility transport (to a higher level of care) determined necessary by the originating facility based upon The Emergency Medical Treatment and Labor Act (EMTALA) regulations and guidelines.
  • Transportation Indicator "C2": Transportation indicator "C2" indicates a patient is being transported from one facility to another because a service or therapy required to treat the patient's condition is not available at the originating facility

Air Ambulance Transport

Air Ambulance is reimbursable when the medical condition is such that transportation by either basic or advanced life support ground ambulance is not appropriate because the patient's condition requires rapid transport to the nearest appropriate facility. Air transport may also be necessary because the patient is inaccessible by a ground or water ambulance vehicle.

Centers for Medicare & Medicaid Services (CMS), Medicare Benefit Policy Manual, Chapter 10 – Ambulance (PDF)

Centers for Medicare & Medicaid Services (CMS), Medicare Benefit Policy Manual, Chapter 15 – Ambulance (PDF)

Noridian Healthcare Solutions, Ambulance Services

Centers for Medicare & Medicaid Services (CMS), Outreach and Education, Medicare Learning Network (PDF)

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