A0428 — Ambulance service, basic life support, non-emergency transport, (bls)
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 services are consideredmedically necessarywhen the following criteria are met (A, B,andC must be met):
- The ambulance must have the necessary equipment and supplies to address the needs of the individual;and
- The individualâs condition must be such that any other form of transportation would be medically contraindicated (for example bed-confined [unable to get up from bed without assistance, unable to ambulate, and unable to sit in a chair or wheelchair]);and
- Either of the following circumstances exists:Transportation to or from one hospital or medical facility to another hospital or medical facility, skilled nursing facility, or free-standing dialysis center in order to obtain medically necessary diagnostic or therapeutic services is required (for example magnetic resonance imaging, computed tomography scan, acute interventional cardiology, intensive care unit [ICU] services [including neonatal ICU], Cobalt therapy, etc.) provided such services are [...]
- Transportation to or from one hospital or medical facility to another hospital or medical facility, skilled nursing facility, or free-standing dialysis center in order to obtain medically necessary diagnostic or therapeutic services is required (for example magnetic resonance imaging, computed tomography scan, acute interventional cardiology, intensive care unit [ICU] services [including neonatal ICU], Cobalt therapy, etc.) provided such services are unavailable at the facility where the individ [...]
- The requested transfer is from an acute care facility to an individualâs home or a skilled nursing facility.
5 Active Policies
ANTHEM-CG-ANC-06 — CG-ANC-06 Ambulance Services: Ground; Non-Emergent
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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