RSNAT Documentation Requirements

Repetitive Scheduled Non-Emergent Ambulance Transport Prior Authorization Request Submission Checklist

Please ensure submission of the below items to facilitate the processing of either initial, resubmission, or expedited requests.


Please access the coversheet from the Forms section and fill out completely for submission. If choosing not to utilize the Noridian coversheet, ensure the below information is supplied.

  • Requestor Information
    • Contact name and telephone number
  • Beneficiary Information
    • Beneficiary name
    • Beneficiary Medicare number
    • Beneficiary date of birth
  • Certification Physician/Practitioner Information
    • Physician/Practitioner name
    • Physician/Practitioner National Provider Identifier (NPI)
    • Physician/Practitioner address
    • Physician/Practitioner Provider Transaction Access Number (PTAN)
  • Ambulance Supplier Information
    • Ambulance supplier name
    • Ambulance supplier NPI
    • Ambulance supplier (PTAN)
    • Ambulance supplier address
  • Other Pertinent Information
    • Submission date
    • Number of transports requested
    • HCPCS code
    • Requested start date of the prior authorization period
    • Indicate if the request is an initial or resubmission review
    • Indicate if the request is expedited and the reason why
    • State where the ambulance is garaged

Required Documentation

Check box if submitted Brief Description
  Physician Certification Statement (PCS)
  Documentation from the medical record to support the medical necessity of the transports
  Beneficiary identification, date of service, and provider of the service should be clearly identified on each page of the submitted documentation
  Documentation that provides detailed medical information, including but not limited to objective description of the patient's signs/symptoms, relevant history, medical condition, mobility, functional, and mental status before and after the ambulance trip, as well as other on-scene information, assessment/exam, treatment/specific monitoring, patient's response to interventions, change in patient's condition, and any other special circumstances
  Medical justification for transport and/or transfer
  All records that justify and support the level of care
  Information on the origin and destination of the transports
  Signature log or signature attestation for any missing or illegible signatures within the medical record (all personnel providing services)
  Any other relevant documentation as deemed necessary to support service


Last Updated Dec 09 , 2023