Authorization Process (RSNAT)

The information submitted will be reviewed by the MAC, and the decision (affirmative or non-affirmative) will be issued to the requester. A provisional affirmation will be issued to the requester if it is decided that applicable Medicare coverage, coding, and payment rules are met. A non-affirmation will be issued to the requester if it is decided that applicable Medicare coverage, coding, and payment rules are not met. A unique tracking number (UTN) will be assigned with each PA request.

Review Decisions and Timeframes

Timeframes for conducting PA request will be dependent upon the service(s) and documentation submitted for PA request. There are three types of review timeframes:

  • Initial Submission - the first PA request sent to the contractor for review and decision. The MAC will complete its review of medical records and send an initial decision letter that is either postmarked or faxed within 10 business days following the receipt of initial request.
  • Resubmission - any subsequent resubmissions to correct an error or omission identified during a PA request decision. A resubmitted PA request is a request submitted with additional/updated documentation after the initial PA request was non-affirmed. The MAC will postmark or fax notification of the decision of these resubmitted requests to the provider or beneficiary within 10 business days of receipt of the resubmission request. The provider should review the detailed decision letter that was provided. A provider may resubmit a PA request an unlimited number of times, upon receipt of a non-affirmative decision. A UTN will be assigned with each PA request resubmission request.
  • Expedited - a PA request decision that is performed on an accelerated timeframe based on the MAC determination that delays in review and response could jeopardize the life or health of the beneficiary. If the MAC substantiates the need for an expedited decision, the MAC will make reasonable efforts to communicate a decision within 2 business days of receipt of the expedited request. The requestor will be notified regarding the acceptance of the PA request for expedited review or if it will convert the request to the standard PA request review process. The affirmative or non-affirmative decision will be rendered within the CMS-prescribed expedited review and will provide the decision to the provider via telephone, fax, electronic portal, or other "real-time" communication, within the requisite timeframe.

Note: The expedited submission should not be used when if the beneficiary's date of service is soon. This timeframe is to only be used when the patient's life and health are in jeopardy. The expedited request must include justification showing the standard timeframe would not be appropriated.

To prevent the claim from denying upon submission, the provider should hold their claim and not submit it until the UTN is provided. The MAC will follow the normal process to obtain a UTN from CMS shared systems.

Decision Letter(s)

The MAC will send decision letters with the UTN to the requester using the method the PA request was received postmarked within the timeframes described above. The MAC will have the option to send a copy of the decision to the requester via fax if a valid fax number was provided, even if the submission was sent via mail. The requester(s) will be notified to hold their claim and not submit until the UTN is received (in order to avoid a claims payment denial).

A copy of the decision letter will be sent to the beneficiary as well.

Decisions

Provisional Affirmation PA Decision

A provisional affirmation PA decision is a preliminary finding that a future claim submitted to Medicare for the service(s) likely meets Medicare's coverage, coding, and payment requirements.

Non-Affirmation PA Decision

A non-affirmation PA decision is a preliminary finding that if a future claim is submitted to Medicare for the requested service does not likely meet Medicare's coverage, coding, and payment requirements. The decision letter for an incomplete PA request will be detailed and the MAC will provide the PA request requester notification of what required documentation is missing or noncompliant with Medicare requirements via fax, mail, or MAC provider portal (when available).

Resubmitting a PA Request

The requestor may resubmit another complete PA request with all documentation required and whatever modifications are needed, as noted in the detailed decision letter. Unlimited resubmissions are permitted. The requestor is encouraged to include the original non-affirmed UTN on the resubmitted PA request.

Claim Submission

Claim Submission without Prior Authorization

Noridian will stop an applicable RSNAT claim for prepayment review if submitted without a prior authorization request decision. The ambulance supplier will receive an additional documentation request (ADR) letter and will have 45 days to respond. Noridian will review the documentation within 30 days from its submission and render a claim determination. Ambulance suppliers do not need to do anything differently when submitting a claim without a UTN.

Affirmed PA Decision on File

Cases where a PA request was submitted and a provisional affirmation PA decision was granted should be submitted to the applicable MAC for adjudication.

Note: If all Medicare coverage, coding, and payment requirements are met, the claim will likely be paid.

  • Claims receiving a provisional affirmation may be denied based on either the following:
    • Technical requirements that can only be evaluated after the claim has been submitted for formal processing; or
    • Information was not available at the time of a PA request
    • We note claims for which there is a provisional affirmation PA decision will be afforded some protection from future audits, both pre- and postpayment; however, review contractors may audit claims if potential fraud, inappropriate utilization, or changes in billing patters are identified.

Non-Affirmed PA Decision on File

Cases where a PA request was submitted and a non-affirmed PA decision was granted should be submitted to the applicable MAC for adjudication.

  • If the claim is submitted to the MAC for payment with a non-affirmative PA decision, it will be denied.
  • All appeal rights are then available.
  • This claim could then be submitted to secondary insurance, if applicable.

Insurance

Note: Whether Medicare is listed as primary or secondary, a prior authorization is required.

Medicare is Primary Insurance

In cases where Medicare is primary and another insurance company is secondary:

Providers who choose to use the PA process to obtain a claim denial should follow the below process:

  • The requester may submit the PA request with complete documentation as appropriate. If all relevant Medicare coverage requirements are not met for the service, then a non-affirmative PA decision will be sent to the provider and beneficiary, advising that Medicare will not pay for the item.
  • After receiving a non-affirmative decision for the PA request, if the associated claim is submitted by the provider to the MAC for payment, it will be denied
  • The provider or beneficiary may forward the denied claim to his/her secondary insurance payer as appropriate to determine payment for the service

In cases where a beneficiary is dually eligible for Medicaid and Medicare, a non-affirmed prior authorization decision is sufficient for meeting states' obligation to pursue other coverage before considering Medicaid coverage. The provider may need to submit the claim to Medicare first and obtain a denial before submitting the claim to Medicaid for payment.

Another Insurance Company is Primary

Cases where another insurance company is primary and Medicare is secondary:

  • The requester submits the PA request with complete documentation as appropriate. If all relevant Medicare coverage requirements are met for the item(s), then a provisional affirmative PA decision will be sent to the provider and to the beneficiary, if specifically requested by the beneficiary, advising them that Medicare will pay for the service.
  • The provider submits a claim to the other insurance company
  • If the other insurance company denies the claim, the provider or beneficiary can submit a claim to the MAC for payment (listing the unique tracking number on the claim).

Claim Appeals

Claims subject to PA requirements under the Repetitive, Scheduled Non-Emergent Ambulance Transport (RSNAT) program follow all current appeals procedures. A PA request that is non-affirmed is not an initial determination on a claim for payment for services provided and, therefore, would not be appealable; however, if a provider has an unlimited number of opportunities to resubmit a PA request, provided the claim has not yet been submitted and denied.

A non-affirmation PA decision does not prevent the provider from submitting a claim. Submission of a such a claim and resulting denial by the MAC would constitute an initial payment determination, which makes the appeal rights available.

For further information, please consult Medicare Claims Processing Manual publication, Chapter 29, Appeals of Claims Decision.

Resources

 

Last Updated Jun 13 , 2022