Medical Review Frequently Asked Questions (FAQs)

Q1. We have had claims selected for medical review. However, we do not have access to the mail at the address to which the additional documentation request (ADR) letters are sent to. Is there a way to have the ADR letters send to us directly?
A1. Yes. Beginning April 4, 2022, you can designate a Medical Record Correspondence Address (MRCA). If the MRCA is active, it will be used for all medical review correspondence/letters. The system will default to the existing provider address if an active MRCA is not available or if a development letter does not involve a medical review request. To update the MRCA utilize the CMS-855I form (Section 2E) for individual physician and non-physician practitioners or the CMS-855B form (Section 2A4) for groups and organizations. The forms are located at: Enrollment Forms.

Q2: What is repetitive scheduled non-emergent ambulance (RSNAT) for prior authorization and when is it going to start?
A2: RSNAT is a prior authorization review for repetitive, scheduled, non-emergent ambulance claims. This would be for repetitive services such as dialysis, cancer treatment, or wound care trips. Ensure documentation included detailed information to support that the ambulance transports are reasonable and necessary. This is going to start for JF on 8/1/2022. More information can be found on the Noridian webpage at: Prior Authorization for Repetitive, Scheduled Non-Emergent Ambulance Transport (RSNAT). The link for the form to be filled out can be found at Forms under the Medical Review Forms Section. Check out the Provider Education and Outreach page for webinars related to RSNAT at Schedule of Events. Also, here is an education on-demand tutorial link related to RSNAT located at Education on Demand Tutorials, find the Ambulance Topic and then look for Prior Authorization of Repetitive Scheduled Non-Emergent Ambulance Transport (RSNAT).

Q3: Where can I find additional information about RSNAT from CMS?
A3: The Centers for Medicare & Medicaid Services (CMS) recently announced the implementation of the RSNAT Prior Authorization Model. The model helps ambulance suppliers ensure that their services comply with applicable Medicare coverage, coding, and payment rules before services are rendered and before claims are submitted for payment. The Ambulance Prior Authorization Operational Guide provides operational details about the RSNAT Prior Authorization model. Additionally, ambulance suppliers can share an Ambulance Prior Authorization Physician/Practitioner Letter with physicians and other entities to help ensure that they obtain the necessary documentation in a timely manner.

Q4: When the RSNAT program starts, what documentation do I need to submit to support medical necessity of RSNAT services?
A4: The beneficiary's condition must require both the ambulance transportation itself and the level of service provided in order for the billed service to be considered medically necessary. Refer to CFR 410.40(e) for medical necessity criteria. Medicare covers medically necessary nonemergency, scheduled, repetitive ambulance services if the ambulance provider or supplier, before furnishing the service to the beneficiary, obtains a physician certification statement (PCS) dated no earlier than 60 days before the date the service is furnished. In all cases, the provider or supplier must keep appropriate documentation on file and, upon request, present it to the contractor. The presence of the signed PCS does not alone demonstrate that the ambulance transport was medically necessary. All other program criteria must be met in order for payment to be made. Documentation from the medical record to corroborate the PCS and the medical necessity of the transports, and any other relevant document as deemed necessary by the MAC to process the prior authorization.

 

Last Updated Mon, 27 Jun 2022 16:39:01 +0000