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Prior Authorization for Non-Emergent Ambulance Transports Back on Track

Prior Authorization for Non-Emergent Ambulance Transports Back on Track

Find out what you’ll need to do to get these claims paid.

Expansion of the Prior Authorization Model for Repetitive, Scheduled Non-Emergent Ambulance Transports (RSNAT) will begin as early as Dec. 1 for some independent ambulance suppliers, according to a notice in the Aug. 27 Federal Register.

Medicare Part B Coding and Coverage

Prior authorization for RSNAT applies to Part B covered ambulance services billed on a CMS-1500 form and/or a HIPAA compliant ANSI X12N 837P electronic transaction using the following HCPCS Level II codes:

A0426 Ambulance service, advanced life support, non-emergency transport, level I (ALS 1-emergency)

A0428 Ambulance service, basic life support, non-emergency transport, (BLS)

According to a Nov. 23, 2020, notice (85 FR 74725 § I.C.), “Non-emergent transportation by ambulance is appropriate if either the (1) beneficiary is bed-confined and it is documented that the beneficiary’s condition is such that other methods of transportation are contraindicated; or (2) beneficiary’s medical condition, regardless of bed confinement, is such that transportation by ambulance is medically required.”

Further, Medicare Part B only covers ambulance transport services when:

  1.  Any other mode of transportation would put the patient at risk; and
  2. The level of service provided by ambulance personnel are needed.

When Will Suppliers Have to Comply with Prior Authorization of RSNAT?

The states that participated in the initial model — Delaware, the District of Columbia, Maryland, New Jersey, North Carolina, Pennsylvania, South Carolina, Virginia, and West Virginia — transitioned to the national model on Dec. 2, 2020. Due to the COVID-19 public health emergency (PHE), the Centers for Medicare & Medicaid Services (CMS) temporarily delayed expansion to additional states. Although the PHE for COVID-19 is ongoing (at the time of this writing), CMS is moving ahead with implementing the prior authorization model nationwide.

Implementation dates for independent ambulance suppliers vary by state (and contractor jurisdiction):

Arkansas, Colorado, Louisiana, Mississippi, New Mexico, Oklahoma, TexasDec. 1, 2021
Alabama, American Samoa, California, Georgia, Guam, Hawaii, Nevada, Northern Mariana Islands, TennesseeNo earlier than Feb. 1, 2022
Florida, Illinois, Iowa, Kansas, Minnesota, Missouri, Nebraska, Puerto Rico, Wisconsin, U.S. Virgin IslandsNo earlier than April 1, 2022
Connecticut, Indiana, Maine, Massachusetts, Michigan, New Hampshire, New York, Rhode Island, VermontNo earlier than June 1, 2022
Alaska, Arizona, Idaho, Kentucky, Montana, North Dakota, Ohio, Oregon, South Dakota, Utah, Washington, WyomingNo earlier than Aug. 1, 2022

What Is the Purpose of Prior Authorization?

Prior authorization is meant to help reduce claims for medically unnecessary services and supplies, thus saving the Medicare program and its beneficiaries money. Making sure all relevant clinical or medical documentation requirements are met before services are furnished to patients helps to:

  • Ensure claims comply with Medicare documentation, coverage, payment, and coding rules the first time; and
  • Reduce prepayment reviews, rejections, and denials that lead to providers having to either appeal or write off unpaid claims.

More background information about RSNAT Prior Authorization Model is available on the CMS website.

How Do I Obtain Prior Authorization?

The model establishes a process for requesting prior authorization for repetitive, scheduled non-emergent ambulance transports and submission of the prior authorized transport claim. See the Repetitive, Scheduled Non-Emergent Ambulance Transport Prior Authorization Model Operational Guide for details.

Although prior authorization is voluntary, Medicare Administrative Contractors (MACs) will only permit three round-trip transports in a 30-day period without it. The fourth and subsequent claims for a patient’s non-emergent ambulance transport in the same 30-day period will be held for prepayment review.

An affirmative prior authorization decision may permit up to 40 round trips in a 60-day period. Authorization for additional trips is decided on a case-by-base basis.

Tip: When submitting a request for prior authorization to the MAC, include all relevant documentation to support Medicare coverage of the transports.

MACs are required to “make every effort” to review and postmark the notification of their decision within 10 business days. An expedited review can be requested by the ambulance supplier or patient if the health of the patient is in jeopardy.

Certain Requirements Remain on Pause Due to COVID-19

Typically, Part B drugs and certain durable medical equipment (DME) require proof of delivery and/or the patient’s signature. In a July 20, 2020, FAQ, however, CMS states, “… claims with dates of service during the COVID-19 PHE (January 27, 2020, until expiration), CMS will not review for compliance with appropriate signature requirements for non-emergency ambulance transports during medical review, absent indication of fraud or abuse.”

Be advised, however: The agency goes on to say, “Ambulance providers and suppliers should indicate in the documentation that a signature was not able to be obtained because of the ongoing COVID-19 pandemic.”

During the COVID-19 PHE, CMS has indicated COVID-19-related hardships will be taken into consideration for things like audit response timeliness. “Waivers and flexibilities in place at the time of the dates of service of any claims potentially selected for review will also be applied,” CMS states in the July 2020 FAQ.

Source: 86 FR 48149, 85 FR 74725

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Renee Dustman
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About Has 737 Posts

Renee Dustman, BS, AAPC MACRA Proficient, is managing editor - content & editorial at AAPC. She holds a Bachelor of Science degree in Media Communications - Journalism. Renee has more than 30 years' experience in journalistic reporting, print production, graphic design, and content management. Follow her on Twitter @dustman_aapc.

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