Prior Authorization Initiatives

Repetitive Scheduled Non-Emergent Ambulance Transport

The Centers for Medicare and Medicaid Services (CMS) will implement a 3 year prior authorization program for repetitive scheduled non-emergent ambulance transports in the states of New Jersey, Pennsylvania, and South Carolina based on where the ambulance company is garaged. A repetitive ambulance service is defined as medically necessary ambulance transportation that is furnished 3 or more times during a 10-day period; or at least once per week for at least 3 weeks (round trips)

Who needs to submit a prior authorization request?
Ambulance suppliers that are not institutionally based that provide Part B Medicare covered ambulance services and are enrolled as an independent ambulance supplier.
Prior authorization for repetitive scheduled non-emergent ambulance transport is voluntary; however, if the ambulance supplier elects not to submit a prior authorization request before the fourth round trip, the claim related to the repetitive scheduled non-emergent ambulance transport will be subject to a pre-payment medical review.

When is this effective?
Novitas will begin accepting prior authorization requests for New Jersey and Pennsylvania on December 1, 2014 for repetitive scheduled non-emergent ambulance transports scheduled to occur on or after December 15, 2014.
Claims for non-emergent ambulance transports with a date of service on or after December 15, 2014 must have completed the prior authorization process or the claims will be subject to prepayment medical review.
Cover Sheets submitted prior to 12/1/2014 will be returned, and not processed.

HCPC Codes subject to Prior Authorization
A0425 – BLS/ALS mileage (per mile)
A0426 – Ambulance service, Advanced Life Support (ALS), non-emergency transport, Level 1
A0428 – Ambulance service, Basic Life Support (BLS), non-emergency transport

Requests need to include:
Completed Prior Authorization Cover Sheet
Physician Certification Statement
Documentation to support diagnosis, certification statement and the medical necessity of repetitive scheduled non-emergent ambulance transport. Include the origin and destination of the transports.

How do I submit a prior authorization request?
Prior Authorization Cover Sheet
Prior Authorization Cover Sheet (Expedited) *I certify the standard timeframe could seriously jeopardize the life or health of the beneficiary
Cover Sheet Completion Instructions

Where on the claim should the unique tracking number be populated?
Electronic 837 Professional Claim
The unique tracking number (UTN) can be submitted in either the 2300 – Claim Information loop or 2400 – Service Line loop in the Prior Authorization reference (REF) segment where REF01 = “G1” qualifier and REF02 = UTN. This is in accordance with the requirements of the ASC X12 837 Technical Report 3 (TR3).
Paper CMS 1500 Claim Form
The unique tracking number (UTN) must populate the first 14 positions in item 23. All other data submitted in item 23 must begin in position 15.

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