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Medicare Pilot Program Requires Prior Authorization for Ambulance Transport Services

On December 1, 2014, the Centers for Medicare and Medicaid Services (“CMS”) launched a three-year pilot program (“the program”) in an effort to curb improper Medicare payments to ambulances providers. Under the program, CMS requires prior authorization for repetitive, scheduled, non-emergent ambulance transport claims billed using the following HCPCS codes: (1) A0425 – BLS/ALS mileage, per mile; (2) A0426 – Ambulance service, Advanced Life Support (ALS), non-emergency transport, Level 1; and (3) A0428 – Ambulance service, Basic Life Support (BLS), non-emergency transport. CMS defines a “repetitive ambulance service” as medically necessary ambulance transportation services that are furnished three or more times in a ten-day period, or at least once per week for at least three weeks. According to CMS, these services are often used by elderly beneficiaries that require transportation for dialysis, cancer, or wound treatment.

The prior authorization the process requires the ambulance provider to request provisional affirmation of coverage by CMS before a service is rendered to a beneficiary and before a claim is submitted for payment. CMS believes that prior authorization will ensure that the ambulance service is medically necessary and meets the applicable Medicare coverage criteria. According to CMS, the Medicare Administrative Contractor (MAC) will make every effort to review the prior authorization request and postmark decisions letters win ten business days. Each prior authorization decision may affirm up to 40 round trips per request in a 60-day period. The prior authorization request submitted by an ambulance provider must include:

  • The beneficiary’s name, Medicare number, and date of birth;
  • The physician’s name, national provide identifier (“NPI”), and address;
  • The provider/provider’s name, NPI, and address;
  • Procedure codes;
  • Submission date of the prior authorization request;
  • Start of the 60-day period;
  • Indicate is the request is an initial or resubmission review;
  • Physician certification statement;
  • Number of transports requested;
  • Documentation from the medical record to support the medical necessity of repetitive transports;
  • Information on the origin and destination of the transports; and
  • Any other relevant document as deemed necessary by the Contractor to process the prior authorization.

For prior authorization requests denied by CMS, the ambulance provider can resolve any identified deficiencies in the request and resubmit the request; this can be done an unlimited number of times. The provider may also choose to provide the service and submit the claim for payment, even when the prior authorization is denied; however, any claim submitted will be denied, and payment can be sought through the Medicare appeals process. Finally, if an ambulance provider has not requested prior authorization before the fourth round trip, any subsequent claim will be stopped and reviewed on a prepayment review basis.

The initial stages of the pilot program apply only to ambulance providers located in South Carolina, New Jersey and Pennsylvania, and do not include ambulance transports included in a covered Part A stay or provided by an institutionally-based ambulance provider. However, even if currently outside the scope of the pilot program, providers should be alerted to CMS’s recent scrutiny of ambulance transport services and may be a sign that providers could be targeted for Medicare audits in the future. If you are an ambulance provider and have any questions regarding the new prior authorization rules or the implications that the new pilot program may have on your practice, please contact an experienced healthcare attorney at 248-544-0888 or via email at wapc@wachler.com.