Effective January 1, 2020, AmeriHealth will cover emergency ambulance response and treatment without transport in accordance with the Commonwealth of Pennsylvania's mandate (Act 103 of 2018) for members enrolled in Pennsylvania products that are subject to the mandate when all the following medical necessity criteria are met:

• the services provided are medically necessary to stabilize the individual’s medical condition;
• the responding emergency medical services (EMS) ambulance is Pennsylvania-licensed and rendering EMS services in the Commonwealth of Pennsylvania;
• the responding EMS ambulance, in accordance with state regulations, is a specially designed and equipped vehicle used to transport the sick or injured;
• the responding EMS ambulance, in accordance with state regulations, is staffed by state certified or qualified staff who can provide basic life support or advanced life support services, as appropriate, at the treating location during the time of the emergency;
• the responding EMS staff provides on scene emergency evaluation and, if necessary, treatment to stabilize the individual's medical condition, and it is subsequently determined that transportation to an acute care hospital or other emergency care facility for additional care is not required, or the individual declines transportation.

HCPCS code A0998 will be considered eligible for reimbursement in a situation where:

1. EMS staff respond to an emergency call and provide on scene emergency evaluation. AND
2. If necessary, provide treatment to stabilize an individual’s condition, but does not provide transportation – either because the medical issue has resolved or the individual declined transportation.

Updated policy

Medical Policy #12.04.02i: Ground Ambulance Services (Emergency and Nonemergency) (AmeriHealth) was updated and posted as a Notification on October 3, 2019 and will go into effect January 1, 2020.

To view the Notification for this policy, visit our Medical Policy Portal.