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Medical Necessity of Ambulance Services

Medicare Part B (Medical Insurance) pays for ambulance transports when you are transported to a Medicare-covered destination, for a medical condition that would endanger your life if transportation occurred by any other means.

 For payment to be made by Medicare the following coverage requirements must be met for ambulance transport:

  1. The transport must be medically reasonable and necessary;
  2. Transportation actually occurred;
  3. The covered destination is local and;
  4. The facility is appropriate to rendered the required care

Medicare ground ambulance transports are covered only to and from the following destinations:

  • Hospitals;
  • Critical access hospitals;
  • Skilled nursing facilities;
  • Beneficiaries home;
  • Dialysis facilities for end-stage renal disease (beneficiaries who require dialysis);
  • Physician office (limited coverage as follows):
  • When the transport is en route to a Medicare-covered destination and the ambulance stops because of the beneficiary’s dire need for professional attention and immediately thereafter, the ambulance continues to the covered destination.

There may be times when the ambulance provider/supplier feels that Medicare might not cover your ambulance transport based on medical necessity. Meaning that other means of transportation could have transported you safely without endangering your life. As a courtesy, an ambulance provider may give you an ABN to notify you that Medicare will not cover the transport and you will be responsible for payment of the transport. Ambulance providers/suppliers are not required to issue an ABN when the ambulance transport is not deemed medically necessary.  

Medicare does not pay for ambulance services when transportation does not occur to a covered destination. If you call the ambulance and then refuse to be transported, the ambulance provider cannot bill Medicare and may bill you for their services.  

If you request the ambulance provider/supplier to submit a claim to Medicare for the ambulance transport, the provider will submit the line item for ambulance transport with a GY modifier. The GY modifier notifies the Medicare system that the service is not covered. When the claim processes, the line item with the GY modifier will deny. You will receive notification of the denial via a remittance advice notice or Medicare summary notice, and will be responsible for the charges.

What You Can Do

If you feel that your claim should have been paid by Medicare, you have the right to an appeal. You may request your ambulance provider submit an appeal on your behalf or you may appeal the denial with Medicare. Appeals must be filed within 120 days from the date of the denial. Appeals information and forms can be found on our website.

Nearest Appropriate Facility: GY Modifier

Medicare will only cover ambulance services to the nearest appropriate medical facility that’s able to give you the medical care you need. If you choose to be transported to a facility farther away, Medicare’s payment will be based on the charge to the closest appropriate facility. Mileage to the more distant facility will be your responsibility.

When an ambulance provider/supplier deems that you were transported to a facility that is beyond the closest appropriate facility they will notify Medicare of the excessive mileage by billing the additional miles with HCPCS code A0888 with a GY modifier.

For example, if the nearest appropriate facility to provide care is ten miles away, however you request that the ambulance transport you to a facility that is 25 miles away. The 15 miles will be billed with A0888 to indicate the miles beyond the closest appropriate facility. The base ambulance rate and covered miles will be paid by Medicare as long as all program requirements are met. You will be responsible for payment of the 15 miles beyond the closest appropriate facility.

When determining the nearest appropriate facility it is important to keep in mind the nearest appropriate facility is the facility that is capable of providing the medical care to treat your condition. The fact that your physician does not treat patients at a particular facility does not disqualify the hospital from being the closet appropriate facility. If you choose a more distant hospital because you want a particular physician or facility, you will be responsible for the mileage beyond the closest appropriate facility.

What You Can Do

Talk to your physician prior to ambulance transports between facilities. Ask your physician why you are being transferred to another facility, and if it is the closest appropriate facility to provide care.

If you feel that your claim should have been paid by Medicare, you have the right to an appeal. You may have your ambulance provider submit an appeal on your behalf or you may appeal the denial with Medicare. Appeals must be filed within 120 days from the date of the denial. Appeals information and forms can be found on our website.

Related Content

Medicare Ambulance Transports (3 MB)

Medical Necessity of Ambulance Services
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