Ambulance PA

Published 11/30/2021

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.

Attention Jurisdiction J Providers: Nationwide expansion of the Repetitive, Scheduled Non-Emergent Ambulance Transport (RSNAT) Prior Authorization Model is planned for 2022. Jurisdiction J (Alabama, Georgia and Tennessee) is included February 1, 2022 as announced by the CMS schedule Prior Authorization of Repetitive, Scheduled Non-Emergent Ambulance Transport | CMS. Information will be shared on this page to keep you informed about the program. Please be sure to register to receive Email Updates.

General Facts About the Program
Who

Ambulance service providers that bill Medicare Part B and render Repetitive Scheduled Non-Emergent Ambulance Transportation 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 is expanding the Repetitive, Scheduled Non-Emergent Ambulance Transport (RSNAT) Prior Authorization Model to Jurisdiction J on February 1, 2022, as the model has 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

The process tests Medicare prior authorization procedures, which are designed to improve quality of service and reduce costs.
How

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

  • Resubmittal decision notifications will be issued within 10 business 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