Background
General information
Coverage policies
Prior authorization request (PAR) submission requirements
Documentation requirements
Expedited requests
Extended affirmation periods for beneficiaries with chronic conditions
Claim Submission requirements
Prior authorization department contact information
Educational events
Quick links and resources
Effective December 1, 2014, for dates of service on or after December 15, 2014, CMS will prior authorize certain repetitive scheduled non-emergent ambulance transports in New Jersey and Pennsylvania.
Effective December 15, 2015, for dates of service on or after January 1, 2016, CMS will prior authorize certain repetitive scheduled non-emergent ambulance transports in Delaware, Maryland, and the District of Columbia.
By submitting a complete cover sheet and the required documentation, a supplier can receive provisional prior authorization for as many as 40 round trips (80 one-way transports) in a 60-day period.
A repetitive ambulance service is defined as a medically necessary ambulance transportation that is furnished three or more times during a 10-day period, or at least once per week for at least 3 weeks (round trips).
HCPCS code A0425 is considered an associated service and will not receive prior authorization.
Ambulance suppliers under review by a unified program integrity contractor (UPIC) are not eligible to submit prior authorization requests.
Question |
Answer |
Who |
Ambulance service suppliers that bill Medicare Part B can receive provisional prior authorization in JL (Delaware, Maryland, New Jersey, Pennsylvania, and the Washington D.C.). |
What |
Suppliers can receive prior authorization for up to 40 non-emergency scheduled round trips (A0426, A0428) or 80 one-way transports in 60 days. For scheduled trips beyond the prior authorized number, a second prior authorization request is required. |
When |
Effective December 1, 2014, for dates of service on or after December 15, 2014, CMS will prior authorize certain repetitive scheduled non-emergent ambulance transports in New Jersey and Pennsylvania. Effective December 15, 2015, for dates of service on or after January 1, 2016, CMS will prior authorize certain repetitive scheduled non-emergent ambulance transports in Delaware, Maryland, and the District of Columbia. |
Where |
Ambulance suppliers garaged in Delaware, Maryland, New Jersey, Pennsylvania, and the Washington D.C. Nationwide expansion dates can be found here. |
Why |
The purpose of the prior authorization program is to reduce improper payments, while maintaining or improving quality of care. It is designed to ensure all relevant coverage, coding, and medical record(s) requirements are met before the service is rendered to the beneficiary and the claim is submitted for payment. |
How |
Submit the prior authorization request. Attach the required medical records. Request decision notifications will be issued within 10 business days of receipt of submission. Resubmittal decision notifications will be issued within 10 business days of receipt. The notification will contain a 14-digit unique tracking number (UTN) that should be submitted in Item 23 on applicable claims. |
For more information on coverage and documentation requirements, refer to:
This reference information can be found on the CMS website at http://www.cms.gov.
The supplier must submit the PAR to us before the service is provided to the beneficiary and before the claim is submitted for processing. The PAR must include all documentation necessary to show that the service meets applicable Medicare coverage, coding, and payment rules.
To meet coverage criteria, the patient's medical record must contain documentation that fully supports the medical necessity for services.
If the normal timeframe jeopardizes the life or health of the beneficiary, an expedited request can be submitted. However, if medical documentation does not support an expedited process, the request will be subject to the normal timeframe.
Request Type: Expedite
If you selected "expedite", please explain why the normal time frame jeopardizes life or health of the beneficiary. Medical documentation must also support the need for an expedited review.
Complete all other required fields on the form.
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 physician certification statement (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.
Prior authorization customer service phone number:
855-340-5975 available Monday – Friday, 8 a.m. – 6 p.m. ET
Fax number:
833-200-9268
Mailing address:
Novitas Solutions
JL/JH Prior Authorization Requests (specify jurisdiction)
PO. Box 3702
Mechanicsburg, PA 17055
Priority mailing address:
Novitas Solutions
Attention: JL/JH Prior Authorization Requests (specify jurisdiction)
2020 Technology Parkway
Suite 100
Mechanicsburg, PA 17050
Please visit our educational event calendars for all available training opportunities and to register to participate in the webinars.
Loading...
