Ambulance Services - Ground Form

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM EFFECTIVE DATE: 12|01|2025 POLICY LAST REVIEWED: 09|17|2025 OVERVIEW Ambulance and medical transport services involve the use of specially designed and equipped vehicles to transport ill or injured patients. These services may involve ground or air transport in both emergency and non- emergency situations. This policy is for ground transport only. MEDICAL CRITERIA Not applicable PRIOR AUTHORIZATION
Prior authorization review is not required. POLICY STATEMENT Medicare Advantage and Commercial Products All emergency and non-emergency medical transport services must meet the following requirements: • comply with all local, state, and federal laws, • must have all the appropriate and valid licenses and permits • must have the necessary patient care equipment and supplies. Emergency Transports The use of ground emergency medical transport services are considered medically necessary when the patient must be transported to the nearest hospital with the appropriate facilities for the treatment of the patient's illness or injury or in the case of an organ transplantation, to the approved transplant facility. Emergency ground ambulance services for deceased individuals are covered when: 1. The individual was pronounced dead while in route or upon arrival at the hospital or destination; or 2. The individual was pronounced dead by a legally authorized individual (physician or medical examiner) after the ambulance call was made, so no transport is needed. The ambulance benefit is a transport benefit, therefore if member refuses transport, then there will be no reimbursement for the ambulance service. However, it the patient is pronounced dead after the ambulance is called, reimbursement will be made. Claims must be filed with modifier QL - Patient Pronounced dead after ambulance called. Non-Emergency Transports
The use of ground ambulance for non-emergency medical transport of bed-confined individuals is medically necessary when the patient’s condition is such that the use of any other method of transportation is contraindicated1 ; the member meets the definition of bed confined2 and it is to a setting other than a physician office.
The use of ground non-emergency medical transport to physician office is not covered even if a member is considered bed confined. The expectation is that if the member meets the definition of bed confined, the physician should go the member's home to provide care, rather than having the member come to the office. Wheelchair assisted ground ambulance services are not covered. Medical Coverage Policy | Ambulance Services

• Ground

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 2 (401) 274-4848 WWW.BCBSRI.COM

Members residing in a skilled nursing Facility (SNF), ambulance transports to or from a diagnostic or therapeutic site such as an independent diagnostic testing facility (IDTF), cancer treatment center, radiation therapy center, wound care center, are covered if member meets the criteria for bed confined.

Members in an acute inpatient facility (hospital, rehabilitation facility or long-term care facility (LTAC)), no payment will be made for transportation from an acute inpatient facility to another for a specialized service with the expectancy of the member returning to the original facility. It is the responsibility of the originating facility to provide these transportation services

1Examples of contraindicated conditions: the member is medically unstable, comatose, requires airway monitoring, requires cardiac monitoring or is dependent on a ventilator.

2bed confined is defined as the individual is unable to get up from bed without assistance; unable to ambulate or unable to sit in a chair or wheelchair. The term "bed confined" is not synonymous with "bed rest" or "nonambulatory". Bed confinement, by itself, is neither sufficient nor is it necessary to determine the coverage for an approved use of ground medical transport. It is simply one element of the patient's condition that may be taken into account in the determination of whether means of transport other than an ambulance were contraindicated.

Medicare Advantage Products only

Non-emergency medical transport services to and from a hospital or non-hospital-based dialysis facility are covered when the members meets the definition of bed confined.

Commercial Products
Non-emergency medical transport services to and from a hospital/non-hospital-based dialysis facility are not covered even if the member meets the definition of bed confined.

COVERAGE Benefits may vary between groups and contracts. Please refer to the appropriate Benefit Booklet, Evidence of Coverage or Subscriber Agreement for applicable ambulance benefits/coverage.

BACKGROUND There are three levels of ambulance service: basic medical care (BLS), advanced emergency medical care (ALS), and air/water ambulance services. This policy refers only to BLS and ALS services. For air and water transport, please see the policy "Ambulance: Air/Water."

Basic ambulance service means at least one member of the ambulance crew is certified at the basic emergency medical technician (EMT) level.

Advanced ambulance service means at least one of the ambulance crew is additionally certified to provide emergency procedures, which at a minimum includes defibrillation and/or synchronized cardioversion.

Ambulance services are categorized as Emergency and Non-Emergency.

Emergency ambulance services are covered when the sudden onset of a medical condition manifests itself by acute symptoms of such severity (including severe pain) that the absence of immediate medical attention could reasonably be expected to result in any of the following:

1. Placement of the patient's health in serious (life-threatening) jeopardy;
2. Serious (life-threatening) impairment to bodily functions; or

3. Serious (life-threatening) dysfunction of any organ or bodily part.

   Definition of Medical Necessity for non-emergency transports

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 3 (401) 274-4848 WWW.BCBSRI.COM

Blue Cross & Blue Shield of Rhode Island (BCBSRI) follows The Center for Medicare and Medicaid Services (CMS) definition of medical necessity. Medical necessity is established when the patient's condition is such that use of any other method of transportation is contraindicated. In any case in which some means of transportation other than an ambulance could be used without endangering the individual's health, whether or not such other transportation is actually available, no payment may be made for ambulance services. In all cases, the appropriate documentation must be kept on file and, upon request, presented to the plan. It is important to note that the presence (or absence) of a physician’s order for a transport by ambulance does not necessarily prove (or disprove) whether the transport was medically necessary. The ambulance service must meet all program coverage criteria in order for payment to be made. In addition, the reason for the ambulance transport must be medically necessary. That is, the transport must be to obtain a Medicare covered service, or to return from such a service.

CMS Guidelines for Reporting of Mileage
Beginning with dates of service on or after January 1, 2011, for electronic claim submissions only, mileage must be reported as fractional units for trips totaling up to 100 covered miles. When reporting fractional mileage, providers must round the total miles up to the nearest tenth of a mile and the decimal must be used in the appropriate place (e.g., 99.9).

For trips totaling 100 covered miles and greater, providers must report mileage rounded up to the nearest whole number mile (e.g., 999) and not use a decimal when reporting whole number miles over 100 miles.

For trips totaling less than 1 mile, enter a “0” before the decimal (e.g., 0.9).

CODING Medicare Advantage and Commercial Products Note: BCBSRI’s allowance for the ground ambulance includes the services rendered by an emergency medical technician or paramedic, drugs, supplies and cardiac monitoring.

The following HCPCS are covered/when medically necessary when filed with a covered destination modifier combination: A0225 Ambulance service; Neonatal transport, base rate, emergency transport, one way A0425 Ground mileage, per statute mile (see CMS Guidelines for Reporting of Mileage in background section) A0426 Ambulance service, advanced life support, non-emergency transport, Level 1 (ALS1)
A0427 Ambulance service, advanced life support, emergency transport, Level 1 (ALS1- emergency)
A0428 Ambulance service, basic life support, non-emergency transport (BLS) add modifier QL if patient expired before transport A0429 Ambulance service, basic life support, emergency transport (BLS-emergency) add modifier QL if patient expired before transport
A0433 Advanced life support, Level 2 (ALS2)
A0434 Specialty care transport (SCT)

The following HCPCS codes are non-covered for Medicare Advantage and Commercial Products: A0021 Ambulance service; outside state per mile, transport
A0080 Non-emergency transportation, per mile - vehicle provided by volunteer (individual or organization), with no vested interested A0090 Non-emergency transportation, per mile - vehicle provided by individual (family member, self, neighbor) with vested interstate
A0100 Non-emergency transportation; taxi
A0110 Non-emergency transportation and bus, intrastate or interstate carrier A0120 Non-emergency transportation: mini-bus, mountain area transports, or other transportation systems A0130 Non-emergency transportation: wheelchair van A0140 Non-emergency transportation and air travel (private or commercial) intrastate or interstate A0160 Non-emergency transportation: per mile case worker or social worker

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 4 (401) 274-4848 WWW.BCBSRI.COM

A0180 Non-emergency transportation; ancillary: lodging-recipient
A0190 Non-emergency transportation; ancillary: meals recipient
A0200 Non-emergency transportation; ancillary: lodging escort
A0210 Non-emergency transportation; ancillary: meals escort
A0432 Paramedic intercept (PI), rural area transport furnished by a volunteer ambulance company which is prohibited by state law from billing third-party payers
A0888 Non-covered ambulance mileage A0998 Ambulance response and treatment, no transport
S0209 Wheelchair van, mileage, per mile

The following codes are covered but not separately reimbursed for Medicare Advantage and Commercial Products: A0170 Transportation ancillary: parking fees, tolls, other
A0380 BLS mileage (per mile)
A0382 BLS routine disposable supplies
A0384 BLS specialized service disposable supplies, defibrillation (used by ALS ambulances and BLS ambulances in jurisdictions where defibrillation is permitted in BLS ambulances)
A0390 ALS mileage (per mile)
A0392 ALS specialized service disposable supplies; defibrillation (to be used only in jurisdictions where defibrillation cannot be performed by in BLS ambulances) 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
A0422 Ambulance (ALS or BLS) oxygen and oxygen supplies, life sustaining situation S0207 Paramedic intercept, non-hospital-based ALS service (non-voluntary), non-transport S0208 Paramedic intercept, hospital-based ALS service (non-voluntary), non-transport

S0215 Non-emergency transportation, per mile
93005 Routine ECG with at least 12 leads tracing only, without interpretation and report
93041 ECG, 1 to 3 leads tracing only, without interpretation and report

Modifiers: BCBSRI requires origin and destination modifiers (see below) be appended to all ambulance HCPCS codes on claims submissions. Absence of the two-digit HCPCS ambulance service modifier may cause the claim to deny.

The following is the list of HCPCS ambulance destination modifiers: D - Diagnostic or therapeutic site other than -P or -H when these are used as origin codes E - Residential, domiciliary, custodial facility (other than SNF) G - Hospital-based dialysis facility (hospital or hospital related) H - Hospital I - Site of transfer (e.g., airport or helicopter pad) between modes of ambulance transport J - Non-hospital-based dialysis facility N - Skilled nursing facility (SNF) (1819 facility) P - Physician's office
R - Residence S - Scene of accident or acute event X - (Destination only code) Intermediate stop at physician's office on the way to the hospital

Medicare Advantage Products The following destination modifier combinations are not covered: EP, PE, RP, PR, NP, PN

Commercial Products

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 5 (401) 274-4848 WWW.BCBSRI.COM

The following destination modifier combinations are not covered: EP, PE, RP, PR, NP, PN, RG, GR, RJ, JR

RELATED POLICIES None

PUBLISHED Provider Update, March/September/October 2025 Provider Update, March 2024 Provider Update, April 2023 Provider Update, April 2022 Provider Update, March 2021

REFERENCES:

1. Medical Claims Processing Manual Chapter 6 SNF Inpatient Part A Billing and SNF consolidated billing Section 20.3 and section 20.3.1
2. Medical Claims Processing Manual Chapter 10 Ambulance
3. Rhode Island General Laws: Title 27- http://webserver.rilin.state.ri.us/Statutes/TITLE27/27-20/27-20- 55.HTM

4. Medicare Claims Processing Manual Chapter 15 - Ambulance; Section 30.2.1
   .https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c15.pdf

   i ii

   This medical policy is made available to you for informational purposes only. It is not a guarantee of payment or a substitute for your medical judgment in the treatment of your patients. Benefits and eligibility are determined by the member's subscriber agreement or member certificate and/or the employer agreement, and those documents will supersede the provisions of this medical policy. For information on member-specific benefits, call the provider call center. If you provide services to a member which are determined to not be medically necessary (or in some cases medically necessary services which are non-covered benefits), you may not charge the member for the services unless you have informed the member and they have agreed in writing in advance to continue with the treatment at their own expense. Please refer to your participation agreement(s) for the applicable provisions. This policy is current at the time of publication; however, medical practices, technology, and knowledge are constantly changing. BCBSRI reserves the right to review and revise this policy for any reason and at any time, with or without notice. Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association.

   CLICK THE ENVELOPE ICON BELOW TO SUBMIT COMMENTS