CMS Issues Notice About Prior Authorization Model in PA, NJ and SC

Requests Can Start on December 1, 2014

On November 13, 2014, CMS issued a Notice in the Federal Register officially announcing a 3-year Medicare Prior Authorization model for repetitive scheduled non-emergent ambulance transports in the states of New Jersey, Pennsylvania, and South Carolina.  The new model means that certain ambulance services in these three states must soon obtain prior authorization for repetitive, scheduled non-emergent transports by submitting a host of documentation to their Medicare Administrative Contractors (MACs).

For an official copy of the Notice, click HERE.  You can also link to additional information about the prior authorization model, including the types of documentation that will have to be submitted to a MAC at:

Affected ambulance suppliers can start submitting prior authorization requests on December 1, 2014 to either Novitas or Palmetto, and agencies should be preparing now for this new model.  This model is effective for Medicare-covered repetitive, scheduled non-emergent transports occurring on or after December 15, 2014.

Here's PWW's Summary of the Notice:

Why CMS Is Doing This

CMS says it's trying to crack down on "high incidences of improper payments" for non-emergency transports.  The agency points to the rapidly increasing number of Basic Life Support (BLS) non-emergent transports over the past few years, citing findings from several reports including:

  • The GAO's October 2012 ambulance cost report which detailed a 59 percent increase in BLS-NE transports from 2004 to 2010.
  • The OIG's 2006 study, “Medicare Payments for Ambulance Transports,” indicating a 20 percent nationwide improper payment rate for non-emergent ambulance transports.
  • The June 2013 MedPAC report that found during the 5-year period between 2007 and 2011, the volume of transports to and from a dialysis facility increased 20 percent, more than twice the rate of all other ambulance transports combined.

The agency is using the prior authorization process to "ensure that all relevant clinical or medical documentation requirements are met before services are rendered to beneficiaries and before claims are submitted for payment."

Types of Transports to Which the Model Applies  

The prior authorization model applies to repetitive, scheduled non-emergent ambulance transportsand it will affect the following ambulance HCPCS codes:

  • A0425 Ambulance service, basic life support (BLS)/advanced life support (ALS) ground mileage (per statute mile).
  • A0426 Ambulance service, advanced life support, non-emergency transport, Level 1 (ALS1).
  • A0428 Ambulance service, basic life support (BLS), non-emergency transport.

What Ambulance Services Are Affected?  

This model affects ambulance suppliers garaged in 3 states - New Jersey, Pennsylvania, and South Carolina. Although the Notice states throughout that it applies to ambulance "providers/suppliers," CMS stated in several Special Open Door Forums, and in its reference materials about the model, that the model affects suppliers only (not institutionally based ambulance providers).

How Long Will the Model Last?  

Right now, the model is slated to be in effect for 3 years.  However, it could be extended in the future, and to other states.

When a Supplier Should Obtain Prior Authorization Under the Model

Suppliers should submit to the MAC a request for prior authorization, along with all relevant documentation to support Medicare coverage of a repetitive scheduled non-emergent ambulance transport, before the fourth round trip in a 30-day period.  CMS is taking the position that, for this model,  a repetitive ambulance service is defined as "medically necessary ambulance transportation that is furnished in 3 round trips or more times during a 10-day period, or at least once per week for at least 3 weeks."  We recommend that ambulance services submit a prior authorization request as soon as they know a patient is going to require scheduled, repetitive non-emergent ambulance services on an ongoing basis.

Review Time Periods 

After receipt of all documentation, CMS says the MACs will make every effort to conduct a review and postmark the notification of their decision on a prior authorization request as follows:

  • Initial Requests - 10 business days
  • Subsequent Requests (after a nonaffirmative decision on an initial prior authorization request) - 20 business days
  • Expedited Review -  2 business days  

How Many Trips Can be Approved?

A MAC may approve up to 40 round trips (which equates to 80 one-way trips) per prior authorization request in a 60-day period. Or a MAC may affirm less than 40 round trips in a 60-day period, or may affirm a request that seeks to provide a specified number of transports in less than a 60-day period. Transports exceeding 40 round trips (or 80 one-way trips) in a 60-day period will require an additional prior authorization request.

The Scenarios Under the Model 

CMS outlines several scenarios under the prior authorization model in its Notice:

  • Scenario 1 - Authorization Approved: When an ambulance supplier or beneficiary submits a prior authorization request to the MAC with appropriate documentation and all relevant Medicare coverage and documentation requirements are met for the ambulance transport, the MAC will send a provisional affirmative prior authorization decision to the ambulance supplier and to the beneficiary. When the claim is submitted to the MAC by the ambulance supplier, it is linked to the prior authorization via the claims processing system and the claim will be paid so long as all Medicare coding, billing, and coverage requirements are met. However, after submission, the claim could be denied for technical reasons, such as the claim was a duplicate claim or the claim was for a deceased beneficiary. In addition, a claim denial could occur since certain documentation, such as the trip record, needed in support of the claim cannot be reviewed on a prior authorization request.​
  • Scenario 2 - Non-Affirmative Decision: When an ambulance supplier or beneficiary submits a prior authorization request, but all relevant Medicare coverage requirements are not met, the MAC will send a nonaffirmative prior authorization decision to the ambulance supplier and to the beneficiary, advising them that Medicare will not pay for the service. The supplier or beneficiary may then resubmit the request with documentation showing that Medicare requirements have been met. Alternatively, an ambulance supplier could render the service, and submit a claim with a nonaffirmative prior authorization tracking number, at which point the MAC would deny the claim. The ambulance supplier and/or the beneficiary would then have the Medicare denial for secondary insurance purposes and would have the opportunity to submit an appeal of the claim denial if they believe Medicare coverage was denied inappropriately.
  • Scenario 3 - Incomplete Documentation: When an ambulance supplier or beneficiary submits a prior authorization request with incomplete documentation, a detailed decision letter will be sent to the ambulance supplier and to the beneficiary, with an explanation of what information is missing. The ambulance supplier or beneficiary can rectify the situation and resubmit the prior authorization request with appropriate documentation. 
  • Scenario 4 - Prior Authorization Not Requested: When an ambulance supplier renders a service to a beneficiary that is subject to the prior authorization process, and the claim is submitted to the MAC for payment without requesting a prior authorization, the claim will be stopped for prepayment review and documentation will be requested.

CMS Says Only One Prior Authorization Per Beneficiary at a Time

In the Notice, CMS states that "only one prior authorization request per beneficiary per designated time period can be provisionally affirmed."  CMS also states that "if multiple ambulance providers/suppliers are providing transports to the beneficiary during the same or overlapping time period, the prior authorization decision will only cover the provider/supplier indicated in the provisionally affirmed prior authorization request."  Ambulance services should be aware that they may need to have a previous prior authorization canceled and submit a new request if they take over providing non-emergent repetitive transportation to a patient.