Physicians/Practitioners Who Order Ambulance Transport: Helping Your Patients With Prior Authorization

The RSNAT Prior Authorization Model is a Medicare Fee-for-Service program that was recently instituted throughout the National Government Services jurisdictions.

It is important that physicians who are ordering ambulance transports work with ambulance providers to obtain the necessary documentation. This documentation assists the ambulance with their prior authorization request, and in turn, assists your patients in receiving the covered benefits.

A repetitive ambulance service is defined as medically necessary ambulance transportation that is furnished in three or more round trips during a ten-day period; or at least one round trip per week for at least three weeks. Medicare may cover repetitive, scheduled, non-emergent transportation by ambulance if:

• Medical necessity requirements are met, and
• The ambulance supplier, before furnishing the service to the beneficiary, obtains a written order from the beneficiary’s attending physician certifying that those medical necessity requirements were met.

What You Need to Know

It is important to understand the prior authorization program does not create new documentation requirements for physicians/practitioners or ambulance suppliers, it simply requires the documentation to be submitted earlier in the claims process. As the ordering physician/practitioner, you are required to supply the ambulance supplier or beneficiary the physician certification statement as well as any other documentation that supports medical necessity for the repetitive, scheduled non-emergent ambulance transport.

The ambulance supplier or beneficiary submits the prior authorization request with accompanying documentation to the appropriate MAC.

The prior authorization request must include all relevant documentation to support Medicare coverage of the transport. This includes, but is not limited to:

• Documentation from the medical record to support the medical necessity of repetitive, scheduled non-emergent ambulance transport
  • Documentation must show transportation by other means is contraindicated
  • Vague statements, such as “patient is bed-confined,” are insufficient
  • Diagnosis of disease or illness may not be enough without corroborating evidence/statements
  • Attestation statements concerning the patient’s requirements for ambulance transportation are not sufficient without corroborating evidence in the medical documentation
• PCS, including the certifying physician’s name, NPI and address
  • The PCS must be supported by the medical documentation
  • Bed-confinement or need for transportation cannot only be stated on the PCS
  • Procedure codes
• Number of transports requested
  • The prior authorization decision, justified by the beneficiary’s condition, may affirm up to 40 round trips per prior authorization request in a 60-day period
• Information on the origin and destination of the transports
• Any other relevant document as deemed necessary by the MAC to process the prior authorization

For more information on coverage and documentation requirements, please refer to applicable LCDs and Articles found on the Medicare Coverage Database and the Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM) Publication 100-02, Medicare Benefit Policy Manual, Chapter 10.

If your patient does not qualify for Medicare transportation, there may be other state and local services that can help. Beneficiaries, case managers and caregivers may contact Eldercare at 800-677-1116 or their local State Health Insurance Assistance Program. Beneficiaries can also find additional information in the Ambulance Prior Authorization Introductory letter posted on the program website listed below.

Additional information about the program is available at CMS' Prior Authorization and Pre-Claim Review Initiatives. If you have specific questions that are not addressed on this website, please submit questions via e-mail to AmbulancePA@cms.hhs.gov.

Posted 6/9/2022