Article Detail - JF Part B
ACT Questions and Answers - January 25, 2022
ACT Prior Authorization of Repetitive, Scheduled Non-Emergent Ambulance Transports (RSNAT) - January 25, 2022
The following questions and answers (Q&As) are cumulative from the RSNAT Part B Ask the Contractor Teleconference (ACT). Some questions have been edited for clarity and answers may have been expanded to provide further details. Similar questions were combined to eliminate redundancies. If a question was specific just for that office, Noridian addressed this directly with the provider. This session included educational material, pre-submitted questions, and verbal questions posed during the event.
RSNAT Educational Material
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:
- The medical necessity requirements described 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 the medical necessity requirements are met.
Ambulance HCPCS Subject to Prior Authorization
- A0426 - Ambulance service, Advanced Life Support (ALS), non-emergency transport, Level 1
- A0428 - Ambulance service, Basic Life Support (BLS), non-emergency transport
For prior authorization the mileage code, A0425, is treated as an associated procedure and not needed for prior authorization request. Ambulance suppliers are required to bill the mileage code on the same claim as the transport code.
Authorization Decisions and Affirmations
The prior authorization decision, justified by the beneficiary’s condition, may affirm up to 40 round trips (which equates to 80 one-way trips) per prior authorization request in a 60-day period.
- Provisional Affirmation
- Provisional affirmative prior authorization decision may affirm less than 40 round trips or affirm a request that seeks to provide a specified number of transports (40 round trips or less) in less than a 60-day period. A provisional affirmative decision can be for all or part of the requested number of trips.
- Transports exceeding 40 round trips (or 80 one-way trips) in a 60-day period require an additional prior authorization request.
- Provisional affirmative decision is a preliminary finding that a future claim submitted to Medicare for the service likely meets Medicare’s coverage, coding, and payment requirements.
- After the review, Noridian will send the decision letter with the provisional affirmative unique tracking number to the submitter via fax, mail, or the provider portal (when available) postmarked within 10 business days. Decision letters sent via esMD are not available at this time. Noridian will also mail a copy of the decision letter to the beneficiary.
- A provisional affirmative prior authorization decision does not follow the beneficiary. Only one ambulance supplier is allowed to request prior authorization per beneficiary per time period.
- If the initial supplier cannot complete the total number of prior authorized transports, the initial supplier should contact their MAC to cancel their prior authorization. A subsequent ambulance supplier may submit a prior authorization request to provide transport for the same beneficiary and must include the required documentation in the submission.
- Non-Affirmative Decision
- A non-affirmative decision is a preliminary finding that a future claim submitted to Medicare for the service does not meet Medicare’s coverage, coding, and payment requirements.
RSNAT Prior Authorization Submission and Resubmission
Submitters are encouraged to use the form specifically designed for prior authorization requests and submit through postal, fax, portal or ESMD.
- Jurisdiction E Part B (JEB) Submitting a Prior Authorization Request
- Prior Authorization Request for Repetitive, Scheduled Non-Emergent Ambulance Transports Medicare Part B Fax/Mail Coversheet
Resubmissions are permitted. A resubmission is any subsequent submissions to correct an error or omission identified after the initial prior authorization request decision was non-affirmed and prior to claim submission. When a prior authorization request is non-affirmed, the submitter should review the detailed decision letter. The submitter may then resubmit the request with additional documentation showing that Medicare requirements have been met using the same submission procedures. Resubmissions are unlimited during the prior authorization process.
Q1. If a transport is not approved in the prior authorization process, can transports that occur later be submitted with a modifier GY?
A1. Yes. Ambulance suppliers may submit the claim without a prior authorization decision if the claim is non-covered using the GY modifier. Claim submitted with a non-affirmative prior authorization decision will deny. The beneficiary and the supplier have appeal rights.
Question Posed During Event
Q1. Have you heard of the community programs, CEMS? I work for St. Luke’s in ID. They have a community outreach to see several patients during the day who have chronic issues or trans care type patients.
A1. (CEM) or Community Emergency Medical are services coordinated with primary providers that may be provided as a paramedic or EMT service to see the patient in their home. There are some communities (i.e., in AZ) that do offer this. While yes, we have heard of this, the prior authorization program is specific to patient transports.
Webinars are available and can be found on our Schedule of Events. A Webinar-on-Demand recording is available, and inquiries on the program can be submitted through our Provider Contact Center or through email, PartBpriorauth@noridian.com.