Commonwealth of Massachusetts
Executive Office of Health and Human Services
Office of Medicaid
600 Washington Street
Boston, MA  02111
www.mass.gov/masshealth

                                                  MassHealth
                                                  Transmittal Letter TRN-30
                                                  July 2008



	TO:	Transportation Providers Participating in MassHealth

	FROM:	Tom Dehner, Medicaid Director 

	RE:	Transportation Manual (New Service Code and Description)

This letter transmits information related to transportation and introduces a new service code in 
Subchapter 6 (service codes and descriptions) of the Transportation Manual. 

New Service Code

Effective for dates of service on or after September 1, 2005, MassHealth is paying for specialty 
care transport in an ambulance (Service Code A0434). Specialty care transport is defined as a 
medically necessary ambulance transport, for a critically injured or ill person, to provide a level of 
interhospital transportation service that exceeds the scope of the ambulance paramedic’s clinical 
expertise as defined in the National EMS Education and Practice Blueprint. This is necessary 
when a person’s condition requires ongoing care that must be furnished by one or more health 
professionals in an appropriate specialty area (for example, nursing, emergency medicine, 
respiratory care, cardiovascular care, or a paramedic with additional training). 

For all specialty care transports, providers must keep trip log documentation in their files.

*	When the transport does not include additional staff from the originating facility, the ambulance 
provider must include in the trip logs and notes the appropriate paramedic level credentials as 
identified in the Department of Public Health’s Office of Emergency Medical Services regulations.
*	When the transport includes additional staff from the originating facility, the ambulance provider 
must include in the trip logs and notes the names, titles, and signatures of the additional staff.

The following policies apply to prior denied specialty care transport claims and claims billed under a 
different ambulance code.

*	MassHealth will reprocess all claims that were previously denied for Service Code A0434.
*	All paid claims that were billed under a different ambulance service code and that occur within the 
one-year billing deadline, can be adjusted and resubmitted by providers.
*	For all paid claims that were billed under a different ambulance service code and are beyond the 
one-year billing deadline, the provider needs to file an appeal to MassHealth’s Final Deadline 
Appeal Board in accordance with 130 CMR 450.323.

These regulations are effective August 1, 2008.

If you have any questions about the information in this transmittal letter please contact 
MassHealth Customer Service at 1-800-841-2900, e-mail your inquiry to 
providersupport@mahealth.net, or fax your inquiry to 617-988-8974.  


NEW MATERIAL
(The pages listed here contain new or revised language.)

Transportation Manual

Pages vi, 4-3, 4-4, 4-19, 4-20, 6-1, and 6-2

OBSOLETE MATERIAL
(The pages listed here are no longer in effect.)

Transportation Manual

Pages  vi, 6-1, and 6-2 — transmitted by Transmittal Letter TRN-28

Pages 4-3 and 4-4 — transmitted by Transmittal Letter TRN-29

Pages 4-19 and 4-20 — transmitted by Transmittal Letter TRN-27





Commonwealth of Massachusetts
MassHealth
Provider Manual Series
Subchapter Number and Title
Table of Contents
Page
vi
Transportation Manual
Transmittal Letter
TRN-30
Date
08/01/08

6.  Service Codes and Descriptions

Dial-a-Ride Services 		6-1

Taxi Services .		6-1

Wheelchair Van Services 		6-1

Ambulance Services .		6-2

Other Licensed Carriers		6-2

Appendix A.  Directory 		A-1

Appendix B.  Enrollment Centers 		B-1

Appendix C.  Third-Party Liability Codes 		C-1

Appendix W.  EPSDT Services:  Medical Protocol and Periodicity Schedule		W-1

Appendix X.  Family Assistance Copayments and Deductibles		X-1

Appendix Y.  REVS Codes/Messages 		Y-1

Appendix Z.  EPSDT/PPHSD Screening Services Codes 		Z-1
          

























Commonwealth of Massachusetts
MassHealth
Provider Manual Series

Transportation Manual
Subchapter Number and Title
4 Program Regulations
  (130 CMR 407.000)
Page
4-3

Transmittal Letter
TRN-30
Date
08/01/08
 
Shared Ride — transportation service provided to two or more members traveling in the same 
vehicle (for example, taxi or dial-a-ride) for the purpose of receiving medical services covered 
by MassHealth.

Specialty Care Transport — a medically necessary ambulance transport, for a critically injured 
or ill person, to provide a level of interhospital transportation service that exceeds the scope of 
the ambulance paramedic’s clinical expertise as defined in the National EMS Education and 
Practice Blueprint.  Such transportation is necessary when a person’s condition requires ongoing 
care that must be furnished by one or more health professionals in an appropriate specialty area 
(for example, nursing, emergency medicine, respiratory care, cardiovascular care, or a 
paramedic with additional training).

Taxi — a motor vehicle for hire that is used to transport persons on an individual basis and is 
licensed by the city or town in which the business is located.

Urgent Care — medical services that are not primary care, and are needed to treat a medical 
condition that is not an emergency medical condition.

Verbal Authorization — authorization of transportation by telephone or other verbal means 
obtained from the MassHealth agency when a Prescription for Transportation (PT-1) has been 
signed by the prescriber but has not been received by the MassHealth agency or when urgent 
medical care is required.  
		
Waiting Time — the time spent by a vehicle and its driver and attendants in waiting to return a 
member to the point of trip origin.  Waiting time applies only when the member is not in the 
vehicle.

Wheelchair Van — a motor vehicle that is specifically equipped to carry one or more persons 
who are mobility-handicapped or using a wheelchair.

407.403:  Eligible Members

(A)	(1)  MassHealth Members.  The MassHealth agency covers transportation services only 
when provided to eligible MassHealth members, subject to the restrictions and limitations 
described in MassHealth regulations.  MassHealth regulations at 130 CMR 450.105 
specifically state, for each MassHealth coverage type, which services are covered and 
which members are eligible to receive those services.
(2)  Recipients of the Emergency Aid to the Elderly, Disabled and Children Program.  For 
information on covered services for recipients of the Emergency Aid to the Elderly, 
Disabled and Children Program, see 130 CMR 450.106.

(B)  For information on verifying member eligibility and coverage type, see 130 CMR 450.107.

407.404:  Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services

	 The MassHealth agency pays for all medically necessary transportation services for 
EPSDT-eligible members in accordance with 130 CMR 450.140 et seq., without regard to 
service limitations described in 130 CMR 407.000, and with prior authorization.
  




Commonwealth of Massachusetts
MassHealth
Provider Manual Series

Transportation Manual
Subchapter Number and Title
4 Program Regulations
  (130 CMR 407.000)
Page
4-4

Transmittal Letter
TRN-30
Date
08/01/08


407.405:  Provider Eligibility:  In State

(A)  In order to be eligible to receive payment from MassHealth, a potential provider must be a
Medicare provider, complete a provider application form, and be assigned a MassHealth 
provider number by the MassHealth agency.

(B)	The provider must ensure that drivers and attendants, prior to any contact with a 
MassHealth member, provide written references and undergo a Criminal Offender Record 
Information (CORI) check. The CORI must be in compliance with guidelines that the Executive 
Office of Health and Human Services may issue. The CORI must remain on file at the 
transportation provider’s place of business and the CORI must be conducted annually thereafter.

(C)  Except where the MassHealth agency elects to limit and/or terminate provider agreements 
in accordance with 130 CMR 407.407 and 450.109 in areas of the state where a selective 
contract with a transportation broker is in effect, the MassHealth agency accepts and approves 
applications from providers that qualify and meet given regulations or licensure requirements as 
are adopted by the Massachusetts Department of Public Health, the MassHealth agency, or the 
Massachusetts Registry of Motor Vehicles for one or more of the following modes of 
transportation:  dial-a-ride, taxi, wheelchair van, ambulance, or other licensed carriers.

407.406:  Provider Eligibility:  Out-of-State Emergency Services

	An out-of-state transportation provider may be paid by the MassHealth agency for 
transportation services provided in accordance with 130 CMR 407.000 only if the provider is a 
Medicare provider, submits an application to become an approved MassHealth provider, and is 
assigned a MassHealth provider number by the MassHealth agency.  An out-of-state provider 
must have a valid license issued by the appropriate regulatory agency within its state in order to 
be approved as a MassHealth provider.

407.407:  Selective Contracting

(A)  In some regions the MassHealth agency may provide transportation services through 
selective contracts with regional transit authorities or other transportation entities.  In areas of 
the state where a selective contract with a transportation broker is in effect, services are provided 
in accordance with all applicable MassHealth regulations and the terms of the contract.

(B)  The MassHealth agency may terminate, in whole or in part, existing provider agreements 
with transportation providers in those regions where selective contracts are in effect.  In the 
event of any such termination, the MassHealth agency notifies the affected providers in writing, 
at least 30 days before termination.  Such termination will not affect payments to providers for 
services provided before the date of termination.

(C)  Members in regions where selective contracts are in effect are notified by the MassHealth 
agency of the transportation available to them under the terms of such contracts.

(130 CMR 407.408 through 407.410 Reserved)
Commonwealth of Massachusetts
MassHealth
Provider Manual Series
Subchapter Number and Title
4 Program Regulations
130 CMR 407.000
Page
4-19
Transportation Manual
Transmittal Letter
TRN-30
Date
08/01/08

(5)  Neurological Conditions.  A member who has any of the following neurological 
conditions always requires transportation by ambulance:
(a)  continual confinement to bed (because of severe brain damage, for example); or
(b)  comatose.

(C)  Medical Necessity Form Requirement.
(1)  Emergency ambulance trips do not require a Medical Necessity Form. However, the 
nature of the emergency must be supported by medical records at the hospital to which the 
member was transported.
(2)  Nonemergency ambulance transportation requires a Medical Necessity Form completed 
in accordance with 130 CMR 407.421(D).

(D)  Prior-Authorization Requirement.  In addition to a Medical Necessity Form, the 
MassHealth agency requires prior authorization for all out-of-state nonemergency transportation 
by an ambulance.

(E)  Recordkeeping Requirement.  Providers of ambulance services must keep records of all 
services billed to the MassHealth agency. Such records must be maintained in accordance with 
130 CMR 450.205 and must include a log or trip sheet, separate from the claim form, 
containing the vehicle number, the time of the trip, the driver's name, the name of the member 
transported, the date of service, the origin and destination of the trip, and the nature of the 
ambulance service provided. For emergency trips, the nature of the emergency must be recorded 
in detail, including referring source. If two or more persons are transported together, the 
provider must record the name of all passengers on the log or trip sheet. For specialty care 
transport, such records must include the appropriate paramedic level credentials of the 
ambulance staff or, if originating facility staff is on the vehicle, then such records must include 
staff names, titles, and signatures.

(F)  Rates of Payment.  
(1)  The rate of payment for a Class I and Class II ambulance service is the lowest of the 
following:
(a)  the provider's usual and customary fee;
(b)  the provider's actual charge; or
(c)  the fee set by the Division of Health Care Finance and Policy.
(2)  An ambulance trip may be considered to be a round trip if the waiting time exceeds one 
hour. Payment for such trips is double the base fee, plus mileage per loaded mile after 20 
miles each way.
(3)  When two patients are transported in the same vehicle, payment for the MassHealth 
member is one-half the base fee.  In such instances, the mileage fee applies only once.
(4)  The MassHealth agency does not pay for additional or supplemental fees for oxygen 
service, for a nurse or extra attendant, or for waiting time.
 (5)  The service codes that must be used when billing for ambulance services are listed in 
Subchapter 6 of the Transportation Manual.

(130 CMR 407.482 through 407.490 Reserved.)






Commonwealth of Massachusetts
MassHealth
Provider Manual Series
Subchapter Number and Title
4 Program Regulations
130 CMR 407.000
Page
4-20
Transportation Manual
Transmittal Letter
TRN-30
Date
08/01/08

407.491:  Other Licensed Carriers 

(A)  Criteria for Use.  The MassHealth agency pays for services provided by a licensed carrier in 
the following circumstances:
(1)  when there is no transportation provider in the member's locality or when it is less 
expensive to use a licensed carrier (for example, train) than a transportation provider;
(2)  when the member is traveling to specialized medical care that is a great distance from 
home and has obtained approval from the MassHealth agency; or
(3)  when the member lives on an island accessible only by boat or airplane.

(B)  Authorization Requirement.
(1)  All airplane transportation requires prior authorization from the MassHealth agency.
(2)  All train, boat, or private bus transportation requires prior authorization from the 
MassHealth agency. If the licensed carrier is not a MassHealth provider, the member may 
pay for services directly and request reimbursement as set forth in 130 CMR 407.431.
(3)  If the member is traveling outside his or her locality, documentation from a physician is 
required to verify that the necessary medical services cannot be obtained locally.

(C)  Consultation with the Prior Authorization Unit.  The following situations require 
consultation with the Prior Authorization Unit before granting prior authorization for private 
bus, train, or boat:
(1)  when the member is traveling outside his or her locality to obtain medical care; and
(2)  when a member is traveling out of state to obtain medical care, except when the 
destination is a town or city within the member's locality.

(D)  Rates of Payment.  Rates of payment for licensed carriers is the carrier's usual and 
customary charge, not to exceed established legal rates, if any.  The service codes that must be 
used when billing are listed in Subchapter 6 of the Transportation Manual.

(E)  Billing Procedures.  Billing procedures for other licensed carriers who have provided 
transportation in special circumstances for which they have received prior authorization requires 
consultation with the MassHealth agency.


REGULATORY AUTHORITY

130 CMR 407.000:  M.G.L. c. 118E, §§ 7 and 12.










Commonwealth of Massachusetts
MassHealth
Provider Manual Series
Subchapter Number and Title
6.  Service Codes and Descriptions
Page
6-1
Transportation Manual
Transmittal Letter
TRN-30
Date
08/01/08

601  Service Codes and Descriptions:  Dial-a-Ride Services

Service
Code		Modifier	Service Description

A0120	Nonemergency transportation:  mini-bus, mountain area transports, or other 
transportation systems (I.C.)
A0120 	TS 	Nonemergency transportation:  mini-bus, mountain area transports, or other 
transportation systems (I.C.) (when more than two one-way trips are being 
billed for the same member on the same date of service)

602  Service Codes and Descriptions:  Taxi Services

Service	
Code		Modifier	Service Description

A0100	Nonemergency transportation; taxi (Use for one passenger, intra-city 
transportation.)
A0100 	TS 	Nonemergency transportation; taxi (Use for one passenger, intra-city 
transportation.) (when more than two one-way trips are being billed for the 
same member on the same date of service) 

603  Service Codes and Descriptions:  Wheelchair Van Services

Service
Code		Modifier	Service Description

A0130	Nonemergency transportation:  wheelchair van
A0130 	TS 	Nonemergency transportation:  wheelchair van (when more than two one-way 
trips are being billed for the same member on the same date of service)
S0215	Nonemergency transportation; mileage, per mile (Wheelchair vans must use this 
code for mileage.  Do not use A0425.)
S0215 	TS	Nonemergency transportation; mileage, per mile (when more than two one-way 
trips are being billed for the same member on the same date of service) 
(Wheelchair vans must use this code for mileage.  Do not use A0425.)
A0130 	TK	Nonemergency transportation; wheelchair van (extra patient or passenger, non-
ambulance) (No mileage fee allowed.)
A0130 	TK-TS 	Nonemergency transportation; wheelchair van (when more than two one-way trips 
are being billed for the same member on the same date of service) (extra 
patient or passenger, non-ambulance) (No mileage fee allowed.)
T2001	Nonemergency transportation; patient attendant/escort (Use for second attendant.)
T2001 	TS 	Nonemergency transportation; patient attendant/escort (when more than two one-
way trips are being billed for the same member on the same date of service) 
(Use for second attendant.) 





Commonwealth of Massachusetts
MassHealth
Provider Manual Series
Subchapter Number and Title
6.  Service Codes and Descriptions
Page
6-2
Transportation Manual
Transmittal Letter
TRN-30
Date
08/01/08

604  Service Codes and Descriptions:  Ambulance Services

Service 	
Code	Modifier	Service Description

          Ground Mileage

A0425	Ground mileage, per statute mile (Ambulances must use this code for mileage.  Do 
not use S0215.)

	Ambulance Service, Specialty Care Transport

A0434	specialty care transport

      Ambulance Service, Advanced Life Support

A0426	Ambulance service, advanced life support, nonemergency transport, level 1 
	(ALS 1)
A0426 	TS 	Ambulance service, advanced life support, nonemergency transport, level 1 (ALS 1) 
(when more than two one-way trips are being billed for the same member on the 
same date of service)
A0427	Ambulance service, advanced life support, emergency transport, level 1 (ALS 1 – 
emergency)
A0427 	TS	Ambulance service, advanced life support, emergency transport, level 1 (ALS 1 – 
emergency) (when more than two one-way trips are being billed for the same 
member on the same date of service)
A0428	Ambulance service, basic life support, nonemergency transport (BLS)
A0428 	TS	Ambulance service, basic life support, nonemergency transport (BLS) (when more 
than two one-way trips are being billed for the same member on the same date 
of service)
A0429	Ambulance service, basic life support, emergency transport (BLS – emergency)
A0429 	TS 	Ambulance service, basic life support, emergency transport (BLS – emergency) (when 
more than two one-way trips are being billed for the same member on the same 
date of service)
A0433	Advanced life support, level 2 (ALS 2)
A0433 	TS 	Advanced life support, level 2 (ALS 2) (when more than two one-way trips are 
being billed for the same member on the same date of service) Ambulance 
Service, Basic Life Support

605  Service Codes and Descriptions:  Other Licensed Carriers

Service
Code		Modifier	Service Description

A0140	Nonemergency transportation and air travel (private or commercial), intra- or 
interstate
A0140 	TS	               Nonemergency transportation and air travel (private or commercial), intra- or 
interstate (when more than two one-way trips are being billed for the same 
member on the same date of service)
	MassHealth
	Transmittal Letter TRN-30
	July 2008
	Page 2