Submitting a Prior Authorization Request

Ambulance suppliers or beneficiaries should legibly complete the National Government Services Prior Authorization Request for Repetitive, Scheduled Non-Emergent Ambulance Transports. The Cover Sheet is now available and it's also available on our Forms page.

Using this form ensures requests are complete. Please be sure to include the following information in your request.

• The beneficiary's first and last name, MBI, and date of birth
• The certifying physician's name, NPI, PTAN (optional), and address
• The ambulance supplier's name, NPI, PTAN (optional) and address
• The requestor's contact name, telephone number and submission date
• The number of transports required
• HCPCS code (A0426, A0428)
• Requested start date of prior authorization period
• Include whether the request is an initial or resubmission review
• Indicate if the request is expedited and the reason why and
• The state where the ambulance is garaged

Documentation Requirements

Please ensure all of the following relevant documentation is included with the original prior authorization submission:

• Physician Certification Statement – see regulations at 42 CFR Section 410.40(a)
• Number of transports requested
• Medical record documentation to support medical necessity
• Origin and destination information
• Any other relevant documentation deemed necessary by NGS to process the prior authorization

Documentation Checklist for Medical Professionals

• Medical record requirements.
• The record is specific to the date of service that contains objective observations from a patient encounter.
  • Examples: Hospital records, doctors’ and ancillary staff progress notes, SNF records, dialysis facility documents, plan of care, interdisciplinary notes, physical or occupational therapy progress notes, etc.
• The record is current. The date of service for the record is on, or prior to, the start date requested and transport occurs.
• Each page must include the patient identification information (complete name, date(s) of service[s].
• The name, credentials, and signature (handwritten or electronic) of rendering physician or NPP treating the patient must be included.
• Every page of the record is legible and readable.

Supporting the Physician Certification Statement

The record must support a medical condition(s) on the PCS.

Statements such as, “patient reports shortness of breath,” “hypertension,” “generalized weakness,” “bed-confined,” etc., must include the supporting clinical assessment data to justify Medicare payment for ambulance services.

Revised 4/12/2022