February 1, 2020
Provide guidelines for coverage and reimbursement of ambulance services including ground and air ambulance transports.
All products are included, except
- Products where Horizon BCBSNJ is secondary to Medicare (e.g. Medigap).
- ITS Home In-Network
All Insured Individual, Commercial medical plans, and Medicare Advantage Plans, are included. SHBP is also included.
ASO accounts will be included as an Opt-In option for additional claims editing on an account by account basis.
This policy addresses reimbursement related to services included as part of an ambulance transportation service, ambulance modifier usage, provider specialty reporting ambulance.
The ambulance transport benefit covers 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.
Ambulance Providers and Suppliers
Horizon BCBSNJ shall consider for reimbursement procedure codes A0021 and A0225 – A0999 when submitted by an Ambulance Provider or Supplier.
Ambulance services and supplies must be submitted with a Place of Service 41 (Ambulance – Land) or 42 (Ambulance – Air or Water).
An ambulance provider may be an independent ambulance supplier or a hospital-based ambulance service.
Origin and Destination Modifiers
In accordance with industry guidelines, Horizon BCBSNJ requires all ambulance providers or suppliers to report an origin and destination modifier for all billed services on each trip provided. Each ambulance modifier is comprised of a single digit alpha character identifying the origin of the transport in the first position, and a single digit alpha character identifying the destination of the transport in the second position. Ambulance origin and destination modifier definitions are:
- D - Diagnostic or therapeutic site, other than P or H
- E - Custodial facility
- G - Hospital based dialysis facility
- H - Hospital
- I - Site of transfer (i.e. helipad) between ambulances
- J - Non-hospital dialysis facility
- N -Skilled nursing facility
- 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)
Note: When “X” is present within the 2 digit modifier combination, “X” must be in the second digit position preceded by a valid origin digit in the first position. “X” may not be submitted in the first position as the origin of the transport.
When billing for round/multiple trips, bill each leg of the trip on a separate line with the appropriate origin and destination modifier. Claim lines should only contain a single origin and a single destination modifier (see also Transport of Deceased Individuals below).
Non-Covered Origins and Destinations
Certain origins and destinations are not covered when billed with ambulance service and transport codes.
For example, a Physician’s office (P) is not a valid destination, except, under certain circumstances, during the transport, the ambulance stops at a physician's office because of the patient's dire need for professional attention, and immediately thereafter, the ambulance continues to the covered destination (See ‘X’), therefore any modifier where P is the destination shall not be considered for reimbursement.
Non-covered origin/destinations include, but are not limited to: DD, DE, DG, DJ, DP, DS, ED, EE, EP, ES, GD, GG, GJ, GP, GS, HP, HS, ID, IE, IG, IJ, IN, IP, IR, IS, JD, JJ, JP, JS, NP, NS, PD, PE, PG, PJ, PP, PR, PS, RD, RE, RP, RR, RS, SD, SE, SG, SJ, SN, SP, SR, SS, XD, XE, XG, XH, XI, XJ, XN, XP, XR, XS, XX
In accordance with industry guidelines, Horizon BCBSNJ shall consider for reimbursement ground ambulance services (A0427, A0429, or A0433) submitted with destination of hospital (Modifier H), site of transfer (Modifier I), or intermediate stop at physician's office on way to hospital (Modifier X).
Air Ambulance Origin and Destination
The following are the only valid origin and destination modifiers for air ambulance service and transport codes:
- DH (Diagnostic, therapeutic site to hospital)
- EH (Custodial facility to hospital)
- GH (Hospital based dialysis facility to hospital)
- HH (Hospital to hospital)
- HI (Hospital to Site of transfer between modes of ambulance)
- IH (Site of transfer to hospital)
- JH (Non-hospital based dialysis facility to hospital)
- NH (Skilled nursing facility to hospital)
- PH (Physician's office to hospital)
- RH (Residence to hospital)
- SH (Scene of accident to hospital)
- SI (From scene of accident or acute event to Site of transfer between modes of ambulance transport)
Services Included in Ambulance Transportation
In accordance with industry guidelines, Horizon BCBSNJ shall not separately reimburse ambulance supplies and/or additional ambulance services, including but not limited to: oxygen and oxygen supplies (A0422); extra attendants (A0424); disposable supplies (A0382, A0384, A0392, A0394, A0396); and waiting time (A0420) when an ambulance transport service (A0021, A0225, A0426-A0434, A0998, A0999, S9960-S9961) has not been submitted and reimbursed for the same date of service by the same ambulance provider.
Transport of Deceased Individuals
In the case where the member was pronounced dead after the ambulance is called and dispatched but before the ambulance arrives at the scene, reimbursement shall be considered for a BLS service if a ground vehicle or air ambulance is dispatched. In this case, mileage shall not be considered for reimbursement. Services should be submitting using procedure code A0428 with modifier QL (Patient pronounced dead after ambulance called) instead of the origin and destination modifier.
If a provider bills Advanced Life Support services (A0225, A0426, A0247, A0433, and A0434) and/or Emergency Basic Life Support service (A0429), with modifier QL, Horizon BCBSNJ shall recode these services in order to reimburse as BLS non-emergent transport (A0428).
Any additional ambulance services and supplies billed with modifier QL shall be denied.
The procedure codes and nomenclature used in this Policy are subject to revision and/or change by the American Medical Association. In the event of such changes, the Policy will continue to be in force, albeit applied to the new or amended coding so issued until such time as the Policy is reviewed and updated to reflect the new or amended coding.
Horizon BCBSNJ shall only consider ambulance services submitted with valid origin and destination modifiers from ambulance providers and suppliers coded with the correct Place of Service for reimbursement.
Horizon BCBSNJ shall deny non-Ambulance Providers or Suppliers for rendering of ambulance services.
Horizon BCBSNJ shall deny ambulance services with a Place of Service other than 41 (Ambulance – Land) or 42 (Ambulance – Air or Water) when billed on a HCFA 1500 Form.
Horizon shall deny ground ambulance transportation services reported without a valid two-digit ambulance modifier; when “X” is the first digit of the two digit modifier combination; or when Emergency transport (A0427, A0429 or A04233) is submitted without a destination modifier of H, I, or X.
Horizon BCBSNJ shall deny air ambulance transportation services not submitted with an appropriate modifier as defined above.
Horizon BCBSNJ shall recode transport codes submitted with modifier QL to A0428 and shall deny other ambulance services submitted with modifier QL.
Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:
- Group or Individual benefit
- Provider Participation Agreement
- Routine claim editing logic, including but not limited to incidental or mutually exclusive logic, and medical necessity
- Mandated or legislative required criteria will always supersede.
11/25/2019: Policy approved