Ambulance PA

Published 12/05/2024

The Prior Authorization Demonstration for South Carolina began on December 1, 2014, and expanded to North Carolina, Virginia and West Virginia on January 1, 2016. This applied to ambulance suppliers that were not institutionally (hospital)-based that provided Part B Medicare covered ambulance services and were enrolled as an independent ambulance supplier. Prior authorization is a process through which a request for affirmation of coverage is submitted for review before a service is rendered to a beneficiary and before a claim is submitted for payment. Prior authorization helps ensure that applicable coverage, payment and coding rules are met before services are rendered.

The Repetitive, Scheduled Non-Emergent Ambulance Transport (RSNAT) Prior Authorization Model expanded nationally, with Jurisdiction J (Alabama, Georgia and Tennessee) included February 1, 2022, as announced by the CMS schedule Prior Authorization of Repetitive, Scheduled Non-Emergent Ambulance Transport. Information will be shared on this page to keep you informed about the program. Please be sure to register to receive Email Updates.

Update: Change Request (CR) 13711 for RSNAT Prior Authorization (PA) Model Operational Changes Regarding Expedited Requests and Review Timeframes

This CR instructs the A/B Medicare Administrative Contractors (MACs) and the Railroad Retirement Board Specialty Medicare Administrative Contractor (RRB-SMAC) to remove the option to request an expedited PA review and to change the PA review timeframe from 10 business days to seven (7) calendar days under the RSNAT PA Model.

General Facts About the Program
Who

Ambulance service providers that bill Medicare Part B and render RSNAT can receive provisional prior authorization.
What

Providers can receive prior authorization for up to 40 non-emergency scheduled round trips (HCPCS codes A0426, A0428) in 60 days. For scheduled trips beyond the prior authorized number, a second prior authorization request is required.
When
  • Phase I — South Carolina applies to dates of service on or after December 1, 2014
  • Phase II — North Carolina, Virginia and West Virginia applies to dates of service on or after January 1, 2016
  • CMS expanded the RSNAT PA Model to Jurisdiction J on February 1, 2022, as the model met all expansion criteria under section 1834(l)16 of the Social Security Act (the Act) (as added by section 515(b) of the Medicare Access and CHIP Reauthorization Act of 2015 (Pub. L. 114-10) (MACRA).
Where Providers with ambulances garaged in JJ (Alabama, Georgia and Tennessee) and JM (South Carolina, North Carolina, Virginia and West Virginia) should submit prior authorization requests for transports in those states to Palmetto GBA.
Why

Prior authorization 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. 
How

Submit the prior authorization request. Attach the required documentation. Decision notifications will be issued within 10 business days of receipt of submission.

  • Effective January 9, 2025, decision notifications, whether for an initial or resubmission, will be issued within 7 calendar days of receipt
  • The notification will contain a 14-digit unique tracking number (UTN) that should be submitted in Item 23 on applicable paper claims or the electronic equivalent field for electronic claims