Initiate a Prior Authorization Request

Table of Contents

• Initiate a Prior Authorization Request
  • Request Details
  • Requestor’s Information
  • Certifying Physician Information
  • Attachments

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Initiate a Prior Authorization Request

Prior authorization helps ambulance suppliers ensure that their services comply with applicable Medicare coverage, coding, and payment rules before services are rendered and before claims are submitted for payment.

Prior authorization for Repetitive, Scheduled Non-Emergent Ambulance Transport (RSNAT) is voluntary. However, if an ambulance supplier elects not to submit a prior authorization request before the fourth round trip in a 30-day period, upon submission the RSNAT claim will be subject to a prepayment medical review.

You will have the ability to initiate a prior authorization request and submit supporting documentation, electronically via NGSConnex.

1. Click the Prior Authorization button from the NGSConnex homepage.

2. In the Select a Provider panel, click the Select button next to the applicable provider account.

3. Select the Initiate Prior Authorization button.

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Request Details

• Type of Request – click ‘Initial’ or ‘Resubmission’
• Expedited Request – select ‘Yes’ or ‘No’
• Reason for Expedited Request - this field is required if ‘Yes’ is selected in the Expedited Request field
• Procedure Type – will auto-populate with ‘Ambulance Transport (RSNAT)’
• Procedure Code – click the field and select all procedure code(s) you would like included in your request.
  • A0425
  • A0426
  • A0428
• Procedure Code Modifier – after you select the procedure code(s) you will be prompted to select an applicable modifier. Procedure code modifiers are optional.
• Number of Transports Requested – enter the number of transports requested
• From/To Date of Service – Must be submitted no sooner than 60 days prior to the start date of transport and is only good for 120 days or a maximum of 80 round trips.
• UTN – the UTN field is only required to be completed when the ‘Type of Request’ selected is a resubmission. The UTN is provided in the initial decision letter.

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Requestor’s Information

• Requestor’s Name – enter the first and last name of the person requesting the Prior Authorization.
• Requestor’s Phone Number – enter the telephone number of the person we should contact if there are questions regarding the request.
• Requestor’s Email Address – enter the email address of the person we should contact if there are questions regarding the request

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Certifying Physician Information

• Certifying Physician’s First Name
• Certifying Physician’s Last Name
• Certifying Physician’s NPI
• Certifying Physician’s Address:
  • Street Address
  • City
  • State
  • Zip Code

5. Select the Next button to move forward.

6. Enter all of the required ‘Provider Details’ information in the applicable fields. The ‘Provider Details’ information will auto-populate based upon the Part B provider selected, the gray shaded fields are not editable.
   
   If you have more than one location with the same PTAN/NPI you may enter the appropriate location in the Street Address, City, State and Zip Code fields.

• Ambulance Garaged State – click the drop-down arrow and select the state where the ambulance is garaged. National Government Services, Inc. only processes prior authorization requests for ambulances that are garaged in the states listed. Prior authorization requests are to be submitted to the appropriate corresponding Medicare Administrative Contractor, based upon the state the ambulance is garaged in.

7. Select the Next button.

8. Enter all of the required ‘Beneficiary Details’ information in the applicable fields.
   • Medicare Beneficiary Number – You must enter the Medicare beneficiary’s MBI.
   • Medicare Beneficiary First Name – You must enter the first name exactly as it appears on the Medicare card.
   • Medicare Beneficiary Last Name – You must enter the last name exactly as it appears on the Medicare card.
   • Medicare Beneficiary Date of Birth – MM/DD/YYYY format.
     • Beneficiary Address
     • Street Address
     • City
     • State
     • Zip Code
9. Select the Next button to move forward.

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Attachments

1. In the Attachments section you will upload all supporting documentation you would like to submit with your request. You have the option to drag and drop and attachment or browse your computer for an attachment. These file types are accepted, tiff, pdf, doc, docx, docm, xlsx, xls, xlsm, jpg, gif, htm, html, txt. There are no limits on the number of attachments you may include with your response. It is recommended that you limit the size of the attachment to 25 MB or less.
2. Your attachments will display and you can verify that you have added all of the applicable attachments. If an attachment was added in error you may delete it prior to submitting your response by selecting the ‘delete’ icon.
3. Click the Next button to move forward.

4. If you are ready to transmit your request to National Government Services, Inc. select the Submit button.

5. A message will display notifying you that your Prior Authorization request has been submitted successfully. In addition, a confirmation email will be sent to the email address associated with your User Profile.
6. Select the Close button to return to the list and submit another Prior Authorization Request or select the Back button to review the information you submitted with your request.