Prior Authorization of Repetitive Scheduled Non-Emergent Ambulance Transport (RSNAT) Frequently Asked Questions (FAQs)
The following is a list of FAQs CGS Administrators have received since implementation of the RSNAT program in Jurisdiction 15.
Physician Certification Statement
- For RSNAT, can the physician certification statement (PCS) be signed by another person who is not a physician?
- No. This is for repetitive non-emergent transports, not a one-time transport. For repetitive non-emergent transports, the PCS must be signed by a physician. We cannot accept a PCS signed by a physician extender such as a nurse practitioner, physician assistant, registered nurse, social worker, etc. See 42 CFR §410.40
- Are PCS Medicaid forms appropriate?
- No. For Medicare the PCS needs to be signed within 60 days of the requested dates of service. We cannot accept forms that are signed on an annual or 365 days basis. Forms for Medicaid are state required forms, and they have different rules and regulations that need to be followed.
- It is the responsibility of the ambulance supplier to maintain a current PCS on file for Medicare.
- Do the dates of service on the PCS have to match when the physician signs the PCS form?
- The dates of service on the PCS form are taken into consideration. However, the affirmation time period is based on when the physician signs the PCS form.
Prior Authorization Request
- I received an affirmation for a specific number of trips. If I need more trips, do I submit another prior auth request?
- Yes. The provisional affirmation is only for a specific number of trips for a specified period of time. Once those trips have been provided and more are needed, you will need to submit another prior auth request.
- It is recommended you submit the new request for a different start of service date for the additional trips that are needed.
- Will prior authorization claims be excluded from TPE reviews?
- Unified Program Integrity Contractors (UPIC) and MACs may conduct targeted pre-pay and post-pay reviews to make sure claims include documentation the MAC did not require for the prior authorization process. Be sure to maintain all documentation.
- Are ESRD dialysis patients excluded from consolidated billing under part A and therefore need a prior auth request?
- Yes, they will need a prior auth request.
- Per Medicare Claims Processing Manual Chapter 6 §20.3.1 – Ambulance services for residents in a Part A stay are not included in the Part A PPS payment.
- The ambulance trip is to or from a hospital based or nonhospital based ESRD facility (the first or second character (origin or destination) of the HCPCS ambulance modifier is N (SNF), and the other character of the HCPCS ambulance modifier is G (Hospital-based dialysis facility) or J (Non-hospital based dialysis facility)) for the purpose of receiving dialysis and related services excluded from consolidated billing.
Medical Documentation
- What types of medical documentation are needed to support medical necessity?
- We can accept any of the following forms of documentation to support the PCS:
- Physician progress notes
- Nursing progress notes
- PT/OT therapy notes
- Completed MDS that has been signed
- ADL sheets
- Wound care notes
- Ambulance run sheets – not required for prior auth, but are required when the claim is under a pre or post-pay review
- We can accept any of the following forms of documentation to support the PCS:
- What is considered up-to-date or timely medical record documentation?
- Medical documentation should reflect the most current and up-to-date information. In some cases, medical documentation dated 3-6 months would be sufficient. For chronic conditions, medical documentation dated greater than 6 months may be taken into consideration. Timeliness of medical records is taken on a case-by case basis. However, it is best practice to have the most current and up-to-date medical record documentation to support medical necessity.
- Is a letter or email from a physician or caregiver be considered acceptable medical documentation?
- No. While letters are helpful, they are not considered to be acceptable forms of medical documentation.
Unique Tracking Number and Multiple Ambulance Suppliers
- If a supplier is housed in Ohio on a border town but provides services to both Indiana and Ohio patients which MAC would they need to send the prior auth request to?
- An ambulance supplier will need to send their requests to the MAC based on where the ambulance in garaged.
- Can a patient have 2 NPIs on their prior auth request?
- No they cannot. The affirmed UTN will be applied to the primary ambulance NPI. If another ambulance supplier needs to step in to transport the patient for a day, that provider will then submit their claim as a pre-pay review without the affirmed UTN number.
- Per operational guide: Only one ambulance supplier is allowed to request prior authorization per beneficiary per time period.
- Can an affirmed UTN transfer from one MAC to another?
- No, a UTN cannot transfer from one MAC to another. A provisional affirmation does not follow the beneficiary. (RSNAT Prior Authorization Operation Guide, 2021)
- Can a beneficiary have 2 separate prior authorization requests if they are receiving 2 different types of services?
- No. There can only be 1 prior authorization request per ambulance provider per patient.
- If another service is needed such as wound care for the same or overlapping dates of service, the affirmed UTN can be used for those trips as well. The ambulance service will need to keep track of the number of trips requested for the given time period. If more trips are needed, another prior auth request will need to be submitted.
- An ambulance supplier can place 2 different sets of modifiers on the same request form. For instance NJ JN and NH HN.
Submitting Claims
- What do I do if I received a non-affirmed UTN but decide to submit the claim anyway?
- You will need to submit the non-affirmed UTN on the claim.
- Per operational guide: A claim submitted for payment with a non-affirmative prior authorization decision will deny. All appeal rights are then available.
- Does a non-emergent trip to a physician's office, discharge from the hospital, or to the emergency department require a prior authorization?
- No. One-time non-emergent transports do not require a prior authorization.
- If such a trip occurs during a prior authorization date of service time period, the ambulance supplier will need to apply the affirmed UTN to the claim for it to be processed.
- These claims may be subject to prepay reviews
- The trip will still need to meet reasonable and medically necessary guidelines.
- What can an ambulance supplier do when they are submitting claims to prevent claim rejections or delays?
- Suppliers can bill the claim using an affirmed or non-affirmed UTN attached to the claim whenever applicable.
Resources:
- 42CFR §410.40: Coverage of Ambulance Services
- Ambulance Prior Authorization CMS FAQs
- Prior Authorization, RSNAT
- Medicare Benefit Policy Manual Chapter 10 Ambulance Services
- Medicare Claims Processing Manual Chapter 6 §20.3.1
- Medicare Program Integrity Manual Chapter 3§3.2.3
- Prior Authorization of Repetitive Scheduled Non-Emergent Ambulance Transport website
- Repetitive, Scheduled, Non-Emergent Ambulance Transport Prior Authorization Operational Guide
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