The following questions were taken from emails, phone calls and question-and-answer sessions of multiple webinars on the repetitive scheduled non-emergent ambulance transport (A0426 - Ambulance service, advanced life support (ALS), non-emergency transport, Level 1; A0428 - Ambulance service, basic life support (BLS), non-emergency transport) prior authorization pilot program for Jurisdiction L (Delaware, Maryland, New Jersey, Pennsylvania, the District of Columbia).
1. What is the latest date we can submit a prior authorization request?
Prior authorization requests are accepted when they are submitted with all the required information. To avoid claim payment delays, suppliers should submit prior authorization requests 10-15 days before the start of scheduled repetitive services.
2. Will there be any notification for the beneficiary about the decision?
The beneficiary will receive a copy of the decision letter sent to the supplier.
3. Does the prior authorization process expedite payment?
A provisional affirmed decision notification advises the supplier that Medicare is likely to pay for a specified number of services for a specific period (as outlined in the decision letter). Claims with a provisional affirmed prior authorization must be billed with the unique tracking number (UTN) and will likely process routinely.
If prior authorization is not requested, suppliers should expect to receive additional documentation requests (ADRs) to support each date of service billed for repetitive non-emergency ambulance services.
4. When will Prior Authorization for Repetitive Scheduled Non-Emergent Ambulance Transport expand past Jurisdiction L?
Per the Sustainable Growth Rate law, national expansion was anticipated as of January 1, 2017. However, at this time, Medicare has not provided information on further expansion.
1. In the event a beneficiary needs more than the 60 days of transport, when can we request the next prior authorization? We would want to make sure the authorization is back before the current authorization expires.
To avoid payment interruptions, submit the subsequent prior authorization request no later than 10 business days before the end of the 60-day period. On the cover sheet, in the Start Date of Authorization field, specify the start date of the next period. Ensure that date is after the end of the prior 60-day period.
2. What is the earliest we can submit a subsequent prior authorization request?
Medical record requirements determine the earliest possible submission date for a subsequent request. For example, the physician certification statement (PCS) must be valid for the requested start date, and signed and dated no earlier than 60 days in advance of the requested start date. (i.e., for a requested start date of 06/23/15, the signature date on the PCS can be no earlier than 04/24/15).
See questions 1, 7, 10 and 12 under Medical Records and the PCS.
3. Should the ambulance supplier get two prior authorizations if a beneficiary needs dialysis and chemotherapy?
No. The provisional affirmation decision and UTN will prior authorize up to 40 round trips in a 60-day period. Regardless of the treatment sought at the destination, as long as the transports are medically necessary, as supported by the medical records, and are repetitive and scheduled, they are provisionally prior authorized under the UTN.
4. Can we request more trips than we actually need; there may be times when an extra dialysis treatment is needed during the month?
Because these transports are repetitive and scheduled, the supplier should know the number of transports planned for a 60-day period. The maximum number of round trips allowed per 60-day period is 40 (80 transports).
5. Is the assigned UTN to the beneficiary or the transporter? What if a beneficiary wants to switch suppliers?
The assigned UTN is to the beneficiary for transports by one supplier, per requested timeframe.
If the beneficiary wants to switch suppliers, then the beneficiary should contact the supplier with the assigned UTN and request the UTN to be expired. The supplier then would call 855-340-5975 and cancel the UTN.
If a supplier ceases to transport a beneficiary before the UTN expires, that supplier can call 855-340-5975 and cancel the UTN. Afterwards another supplier can submit a request for prior authorization for the beneficiary.
6. Can we have another supplier perform a transport if authorization is given to us and at times when we are unavailable?
Yes, if a supplier does not have a prior authorization, then the supplier would file the claim and a letter requesting additional documentation will be sent for the claim to be medically reviewed before payment.
7. How will a supplier know if there is already an existing prior authorization for another company?
Ask the beneficiary. The beneficiary will receive a decision notification, which will include the UTN. Also, you may submit a prior authorization request and receive a decision letter stating the beneficiary already has an existing UTN for requested dates of service.
8. How can we as a supplier cancel a prior authorization for a different company?
A supplier cannot cancel a UTN for another supplier. If a second supplier determines a beneficiary needs another UTN, that supplier should submit a prior authorization request including a request cover sheet along with a PCS and supporting medical records, and attach a statement explaining the situation.
9. Is there a limit to how many times a specific beneficiary can get UTNs?
No. However, the beneficiary gets one affirmed UTN assigned for transports by one supplier per 60-day period.
See question 10 for additional clarification.
10. What does the supplier have to do if the beneficiary requires more than 80 transports in the 60-day period?
One affirmed UTN assigned to the beneficiary for up to 40 round trips (or 80 transports) by one supplier per 60-day period. If there is a need for transports beyond 40 round trips, submit a subsequent prior authorization request along with medical records that explains the needs of the beneficiary.
11. Are we sending the same coversheet for the resubmission and initial request?
No, use a new cover sheet for each request.
12. What happens if a beneficiary has a non-emergent transport that is not a repetitive transport (i.e., a return trip after an emergency room visit)?
Non-repetitive services are not subject to prior authorization.
Novitas could conduct prepayment reviews on any ambulance claims, including claims for non-repetitive transports, for any beneficiary determined to be a recipient of repetitive ambulance services.
13. I have a beneficiary with a non-affirmed UTN. The beneficiary receives non-repetitive services (such as one-way, one-time transports from the emergency room to the residency). I do not put the UTN on claims for non-repetitive services because non-repetitive services are not subject to prior authorization. However, I received an (prepayment medical review) ADR letter for a claim for a non-repetitive transport.
By provisionally non-affirming a request, Novitas has determined that ambulance transports have not been proven medically necessary. Therefore, non-repetitive transport claims for beneficiaries with a non-affirmed UTN on file could be subject to prepayment medical review.
Novitas may conduct prepayment reviews on any ambulance claims, to include claims for non-repetitive transports, for any beneficiary determined to be a recipient of repetitive ambulance services.
14. Can you once again clarify about the garaging? If I have trucks parked in New York and render services in New Jersey, will I still need to submit for prior authorization?
The demonstration program is for companies with ambulances garaged in Jurisdiction L (Delaware, District of Columbia, Maryland, New Jersey, and Pennsylvania).
15. Can a third party request a prior authorization for a beneficiary on behalf of a supplier?
Yes. In this case, the Contact Name, Contact Phone Number and Contact Fax Number fields on the cover sheet should contain the information of the third party.
However, Novitas cannot discuss a beneficiary with the third party unless the third party has a valid authorization from the beneficiary.
16. In what timeframe is the seventh trip being looked at?
To be repetitive, the service is rendered at least three times in a 10-day period or at least once per week for three consecutive weeks.
17. Who is eligible for expedited review?
The cover sheet for an expedited prior authorization request should only be used if the normal timeframe for a decision could jeopardize the life or health of the beneficiary. The medical records must support the need for the expedited process.
However, if the medical records do not support an expedited process, the request will be subject to standard timeframes.
For an initial request, decision notifications will be issued within 10 business days of receipt.
Resubmission decision notifications will be issued within 20 business days of receipt.
Novitas does not expect to see many expedited requests, as the requests are for non-emergent services.
18. Must the cover sheet be completed for the request to be processed?
To facilitate the prior authorization process, suppliers are encouraged to complete the cover sheet in its entirety.
19. I received a non-affirmed decision and UTN for a specified timeframe. I did not use the UTN for the first three round trips and my claims were rejected. I thought the first three round trips are supposed to process normally. Why did they reject?
If you submitted a prior authorization request for a beneficiary for a specified timeframe and received a decision letter, then you should include the UTN on all (repetitive scheduled non-emergent ambulance transport service) claims with dates of service within that requested timeframe. Otherwise, those claims will reject and will have to be resubmitted with the UTN.
The intent of allowing the first three round trips to process normally, if billed correctly, was to allow suppliers to continue to render services and file claims while waiting for a decision letter.
20. Can we call and request a beneficiary’s MBI?
No. However, if you have access to Novitasphere, you may use the MBI Look-Up Tool to obtain a beneficiary’s MBI or obtain the MBI from the beneficiary.
21. I received an affirmation for 240 trips for a total of 180 days for my last request. Is this something new and can providers request this extended affirmation?
Medicare Administrative Contractors (MACs) may now allow up to 240 one-way trips in a 180-day period per prior authorization request for beneficiaries with chronic conditions that are deemed not likely to change over time and meeting all Medicare requirements for repetitive non-emergent ambulance transport. The medical records must clearly indicate the condition is chronic. In addition, two previous prior authorizations requests must have established that the beneficiary’s medical condition has not changed or has deteriorated from previous requests before the MACs may allow an extended affirmation period.
The decision to allow an extended affirmation period is at MAC discretion. Ambulance suppliers cannot request transports beyond the current maximum of 80 transports per 60-day period.
Ambulance suppliers are responsible for maintaining a valid PCS at all times.
The MACs reserve the right to request the PCS at any time.
Each individual time a patient is transported by ambulance, that transport must be reasonable and necessary regardless of whether a new prior authorization is required.
22. Do providers still have to send documentation even though my patient has been approved for 180 days?
No, you do not need to send in additional documentation once approved for 180 days unless the provider believes the beneficiary’s condition has significantly changed so they no longer meet the chronic conditions criteria.
23. Do I have to send in the new/current PCS or keep it on file if my patient has been approved for 180 days?
You need to keep a current PCS on file in the event it is needed for review.
1. Are we to assume that A0425 is inclusive with the authorization as it relates to either A0426 or A0428? It is not an option on the dropdown.
Only A0426 and A0428 can receive provisional prior authorization. Suppliers should bill for the associated mileage code (A0425) on the claims for A0426 and A0428.
1. Do you need to complete a prior authorization with Medicare or Medicare Advantage (MA) or both?
It applies to Medicare only. MA plans do not participate in this demonstration program. Contact the MA insurer for its specific policies.
2. Does this process only apply to Medicare and not Medicaid?
It applies to Medicare only.
3. If Safeguard Services has requested medical records for beneficiaries, are those beneficiaries eligible to receive prior authorization?
Suppliers and beneficiaries under review by a Zone Program Integrity Contractor (ZPIC) or Unified Program Integrity Contractor (UPIC) are not eligible for the ambulance prior authorization program. Further, other contractors (CERT, ZPICs, UPICs, etc.) may have parameters outside of the prior authorization model that will suspend ambulance claims for another type of review.
If your claim is selected for review, guidance and directions will be provided on the additional documentation request letter from the requesting contractor.
4. How will hospital-owned suppliers be identified on claim submission?
Part A billers are excluded. The model does not apply to hospital ambulances.
5. Are beneficiaries with legal representatives excluded from the prior authorization initiative?
Beneficiaries with a representative payee are included in the repetitive scheduled non-emergent ambulance transportation services prior authorization program.
1. Once the 60-day period is up and we submit a subsequent request, do we need to get the physician to give us new medical records, and does the physician need to see the beneficiary again in order for you to accept it?
The medical records should paint a picture of the beneficiary's current medical condition(s), revealing medical necessity. The PCS must be valid for the requested start date. To be valid, the PCS cannot be dated more than 60 days in advance of the requested start date.
2. What medical records are you looking for from the nursing homes?
Medical records can include, but are not limited to doctor's progress notes, nursing notes, physical or occupational therapy notes, History and Physical, the minimum data set, or nursing care plan.
3. When the beneficiary is a new admission to a nursing facility, where do we get medical records?
Refer to the beneficiary's physician or the beneficiary's previous treatment facility. Requests from the physician or the facility, the History and Physical, progress notes, and/or discharge summary.
4. Does a nephrologist count as an attending physician?
A nephrologist can issue a PCS for a dialysis patient.
5. If I submit a detailed and comprehensive PCS that the physician completes, will it alone qualify as sufficient to support medical necessity?
No. Medical records from the physician or other certified healthcare professionals that support that PCS must also be submitted.
6. How recent should medical records be?
Medical records should be current for the medical condition(s) that necessitate the ambulance transports.
Medical records should be dated on or before the date the PCS was completed and signed.
7. If my PCS captures the beneficiary's medical conditions and diagnoses, what information should be in the medical records?
The medical records should support the statements, and diagnosis code(s) on the PCS. The records should reveal the medical necessity of the type and level of transport services.
8. What information on origin and destination should I include on the PCS or in the medical records?
The PCS or the medical records should contain the exact street address of the origin and of the destination.
9. Does the PCS have to be completed entirely by the attending physician?
Yes. An attending physician should complete, sign and date the PCS. The signature and date should be readable. The physician should print his or her name and credentials on the PCS.
For a PCS to be valid, it cannot be dated more than 60 days in advance of the requested start date. It MUST be signed and dated by the attending physician the day it was completed. The PCS CANNOT be pre or postdated nor should it be copied for repeated use after completion.
10. Does all documentation submitted need to be signed?
11. Why did I receive a start date later than my requested start date?
If the medical records and PCS signature date predate the requested start date (on the cover sheet), then the actual start date will be as requested.
If a date of service in the medical records or if the PCS signature date is after the requested start date, then the actual start date will be either the signature date on the PCS or the date of service within the medical records.
12. Who can create the medical records needed for prior authorization?
The clinician who provided the service to the beneficiary creates a record of the encounter at the time the service is provided. The clinician then signs the medical record after review to authenticate the record; the signature may be either handwritten or electronic. The clinician uses appropriate forms, used by the office or facility in which the service is rendered, for the service provided, and this determines the type of signature.
Note: Documentation/medical records are not to be created by a supplier/provider and then presented to a clinician for signature. Clinicians should not sign documentation/medical records that they themselves have not created.
13. Does the beneficiary meet criteria for non-emergent ambulance transportation if they can’t maneuver stairs safely? What if the beneficiary can’t transfer safely?
Medicare covers ambulance services only if furnished to a beneficiary whose medical condition at the time of transport is such that transportation by other means would endanger the patient’s health. A patient whose condition permits transport in any type of vehicle other than an ambulance does not qualify for Medicare payment. To be deemed medically necessary for payment, the patient must require both the transportation and the level of service provided.
1. I just received a non-affirmed decision with a UTN. What do I do now?
Read the decision in its entirety. The decision letter will specify why your authorization request was provisionally non-affirmed. Take the needed action to collect the medical records, acquire a valid PCS, and then complete a new cover sheet and submit again. Otherwise, you can submit the claim with the non-affirmed UTN. The claim will deny. You then have full appeal rights on the denial.