NGS Review of Prior Authorization Request
Table of Contents
- NGS Review of Prior Authorization Request
- Number of Trips
- Extended Affirmation Periods for Beneficiaries with Chronic Conditions
- Decision Letters
- Resubmitting a Prior Authorization Request
- Submitting a Claim
- Appeals
NGS Review of Prior Authorization Request
Once the prior authorization request is received, the NGS PA team will begin the review process. Our PA team will review and postmark the decision notification within 10 business days for both initial and resubmitted requests. Effective for dates of service on and after 1/9/2025, the PA team will postmark a decision within seven calendar days (includes weekends and federal holidays) for both internal and resubmitted requests. A resubmitted request is a request submitted with additional documentation after the initial prior authorization request was nonaffirmed.
When the standard timeframe for making a prior authorization decision could jeopardize the health of a beneficiary, the ambulance supplier or beneficiary may request an expedited review. If the NGS PA team agrees the standard timeframe would put the beneficiary at risk, they will make reasonable effort to convey a decision within two business days of receipt of all required documentation.
Since the requests are typically for non-emergent transportation services, we request you indicate an expedited review on the prior authorization request form. CMS expects requests for expedited reviews to be extremely rare.
Per CMS, the removal of the expedited review option is effective with dates of service on or after 1/9/2025.
Number of Trips
A provisional affirmation prior authorization decision affirms a specified number of trips within a specific amount of time. The prior authorization decision, justified by the patient’s condition, may affirm up to 40 round trips (which equates to 80 one-way trips) per prior authorization request in a 60-day period.
Alternatively, a provisional affirmative prior authorization decision may affirm less than 40 round trips or affirm a request that seeks to provide a specified number of transports (40 rounds trips or less) in less than a 60-day period. A provisional affirmative decision can be for all or part of the requested number of trips. Transports exceeding 40 round trips (or 80 one-way trips) in a 60-day period will require an additional prior authorization request.
Extended Affirmation Periods for Beneficiaries with Chronic Conditions
The MAC may consider an extended affirmation period for beneficiaries with a chronic medical condition deemed not likely to improve over time. The medical records must clearly indicate that the medical condition is chronic, and the MAC must have established through two previous prior authorization requests that the beneficiary’s medical condition has not changed or has deteriorated from previous requests before allowing an extended affirmation period.
The decision to allow an extended affirmation period is at the MACs discretion. The maximum number of requested trips remains at 40 round trips (80 one-way trips).
- The prior authorization decision for requests meeting the above criteria may affirm up to 120 round trips (which equates to 240 one-way trips) per prior authorization request in a 180-day period.
- Ambulance suppliers are still responsible for maintaining a valid PCS at all times. The MAC reserves the right to request the PCS at any time.
- Each individual patient transport must still be reasonable and necessary, regardless of whether a new prior authorization is required.
Decision Letters
NGS will send a decision letter to the provider, and/or the beneficiary, once the review is complete.
There are three types of decision letters you may receive on a specific PA request:
- Affirmed
- Nonaffirmed
- Rejected
| Decision Letter | Description |
|---|---|
| Rejection |
|
| Affirmed |
|
| Nonaffirmed |
|
*Unique Tracking Number
Each completed prior authorization request is assigned a 14-byte UTN. This number will be used when submitting claims related to the prior authorization request and is included on the decision letter.
Resubmitting a Prior Authorization Request
In the event that the prior authorization request is rejected or nonaffirmed, the requestor may resubmit it. Before resubmitting a prior authorization request, the requestor/ambulance supplier should ensure the following actions are completed:
- Review the decision letter that was provided, as well as the detail letter if one was received.
- Make modifications as needed to the prior authorization package and follow the submission procedures.
- Indicate Resubmission on the request form.
The NGS PA team will notify the provider, and/or the beneficiary, by way of a detailed decision letter postmarked within 10 business days of the review.
A nonaffirmed PA decision cannot be appealed. However, there are no restrictions on the number of times a PA request can be resubmitted.
Submitting a Claim
The UTN from the affirmed decision letter must be included on the claim. Please ensure to follow these specific instructions for adding the UTN to the claim form:
837P Electronic claim
Loop 2300 or 2400, Segment REF
- REF01 = G1
- REF02 = UTN
- If using loop 2400, add the UTN to procedure codes A0426 or A0428
- DO NOT add UTN to loop 2400 for procedure code A0425
- We encourage ambulance suppliers to report mileage and transport codes on the same claim.
CMS 1500 Paper Claim Form
Item 23
- The UTN must be the first 14 positions, and any other data entered into Item 23 begins at position 15.
The claim will be subject to the pre-payment review process if it is received without the UTN. This pre-payment review process will include the need for additional documentation. Therefore, providers must be prepared to submit all requested documentation.
Appeals
The prior authorization model does not include a separate appeal process for nonaffirmative PA decisions. However, a nonaffirmative PA decision does not prevent the ambulance supplier from submitting a claim. Such a submission of a claim and resulting denial by the MAC would constitute an initial determination that would make the appeals process available for disputes by beneficiaries and ambulance suppliers.
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Revised 11/4/2024