A0021, Ambulance service, outside state per mile, transport (medicaid only)
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Key Coverage Criteria
- Non-emergency ground ambulance is medically necessary when (A) equipment/supplies to address needs, (B) transportation contraindicated, and (C) either transfer to another facility for medically necessary services unavailable at initial facility or transfer from acute care facility to home/skilled facility.
- Non-emergency ground ambulance services may be considered medically necessary when the following criteria are met: A. The ambulance must have the necessary equipment and supplies; B. The individual’s condition must be such that any other form of transportation would be medically contraindicated; C. Either (1) transfer between facilities to obtain medically necessary services unavailable at initial facility, or (2) transfer from an acute care facility to home or skilled nursing facility.
4 Active Policies
BCBSIL-MED201.058, Ambulance and Transport Services
BCBSMT-MED201.058, Ambulance and Transport Services
BCBSNM-MED201.058, Ambulance and Transport Services
BCBSOK-MED201.058, Ambulance and Transport Services
Related Codes
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