S0215 — Non-emergency transportation; mileage, per mile
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
Documentation Required
- Review the member's benefit plan, summary plan description, or contract to determine coverage, exclusions, and limitations.
- Check applicable state regulations for restrictions or additional requirements.
- Documentation that Emergency Ground Ambulance Transport criteria in Section I are met.
- Clinical documentation of critical condition and/or unstable vital signs, respiratory status, or cardiac status and documentation supporting one of the listed emergent conditions.
Key Coverage Criteria
- Emergency ambulance transport for sudden onset or significant worsening of a medical condition with symptoms of sufficient severity that, absent immediate transport, a prudent layperson would reasonably expect a serious adverse outcome.
- Transport when the individual's health is placed in serious jeopardy.
- Transport when there is serious impairment to the individual's bodily functions.
- Transport when there is serious dysfunction of the individual's bodily organs or parts.
- Transport services comply with all applicable local, state, and federal laws and possess appropriate, valid licenses and permits.
- The ambulance or transport service is equipped with the necessary patient care equipment and supplies for the patient's condition.
5 Active Policies
ADM1001.005 — Ambulance and Transport Services
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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