Reimbursement Policy Implementation: Ambulance Services

Effective February 1, 2020, Horizon BCBSNJ will change the way we consider and reimburse certain professional claims for ambulance transportation services based on the guidelines of our reimbursement policy, Ambulance Services. Generally, ambulance transport benefits cover the medically necessary transport of a member by ground or air ambulance to the nearest appropriate facility that can treat a member’s condition when any other methods of transportation are contraindicated.

We encourage you to review the details of our Ambulance Services policy.

Based on the guidelines within this reimbursement policy, professional claims for ambulance services rendered February 1, 2020 will be processed as follows.

• Claims for ambulance services rendered by non-Ambulance Providers or Suppliers will be denied. Ambulance providers may be an independent ambulance supplier or a hospital-based ambulance service.

• Claims that do not include valid origin and destination modifiers appropriate for the submitted Place of Service will be denied. For example, a Physician’s office (P) is not a valid destination, except, under certain circumstances. See the policy for details.

• Claims for ambulance services that include a Place of Service other than 41 or 42 will be denied.

• Claims for ground ambulance transportation services will be denied if submitted without a valid two-digit ambulance modifier, or if submitted with two-digit modifier that includes “X” as the first digit.

• Claims for emergency transport services (A0427, A0429 or A04233) that include a destination modifier other than H, I, or X will be denied.

• Certain transport codes appended with modifier QL, indicating that the patient was pronounced dead after the ambulance called, will be reimbursed as Basic Life Support non-emergent transport. Other ambulance services codes appended with modifier QL will be denied.

• Separate reimbursement will not be provided for certain ambulance supplies and/or additional ambulance services.

Unless Horizon BCBSNJ gives written notice that all or part of the above-noted changes have been cancelled or postponed, the changes will be applied to claims for dates of service on and after February 1, 2020.