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Last Modified: 3/15/2024 Location: FL, PR, USVI Business: Part B

Instructions for completing the prior authorization request (PAR) coversheet for repetitive scheduled non-emergency ambulance transport

To submit a prior authorization request, complete the prior authorization coversheet pdf file.
Failure to populate every field listed below could result in delays in processing your request, a non-affirmed decision, or a determination that the request is incomplete and cannot be processed.

Field

Description

Request Type:
Select either Initial, Resubmission or Expedite from the drop-down menu.
If, Resubmission Selected:
Enter the previous Unique Tracking Number (UTN).
If, Expedite Selected:
Enter a brief description why the normal time frame jeopardizes the life or health of the beneficiary.
Number of Trips (Not to Exceed 80 in 60 days):
Enter the number of one-way trips being requested and that are justified by the attached medical records.
Up to 40 roundtrips, or 80 individual transports, within 60 days can be prior authorized.
Start of 60-day period
Enter the “start date” of the first requested scheduled repetitive non-emergent transport, as supported by medical records submitted in MM/DD/YYYY format.
Procedure Code(s):
Enter the non-emergency ambulance procedure code (A0426 or A0428).
If it is necessary to request prior authorization for both non-emergency ambulance codes for the same beneficiary, print the coversheet and write the second procedure code in the Number of Trips field after you enter the number of trips.
Modifier 1
Enter anticipated origin modifier for the beneficiary.
Modifier 2
Enter anticipated destination modifier for the beneficiary.
Supplier Name
Enter the ambulance supplier’s full name.
Supplier NPI
Enter the ambulance supplier’s 10-digit NPI.
Supplier PTAN
Enter the ambulance supplier’s PTAN.
Supplier Address
Enter ambulance supplier’s full street address.
Supplier City, State, Zip
Enter the ambulance supplier’s city, state, and ZIP code.
State where ambulance is garaged
Select FL, PR or USVI from the dropdown menu.
Beneficiary Last Name:
Enter the beneficiary’s full last name, to include Jr. or Sr. as appropriate.
Beneficiary First Name:
Enter the beneficiary’s full first name.
Medicare Beneficiary Identifier:
Enter the beneficiary’s MBI.
Date of Birth (DOB):
Enter the beneficiary’s DOB in MM/DD/YYYY format.
Certifying Physician Name:
Enter the certifying Physician's full name and credentials from the Physician Certification Statement (PCS).
Certifying Physician NPI:
Enter the certifying Physician's 10-digit NPI.
Certifying Physician PTAN:
Enter the certifying Physician's PTAN.
Certifying Physician Address:
Enter the certifying Physician's full street address.
Certifying Physician City, State, Zip:
Enter the certifying Physician's city, state, and ZIP code.
Fax number (if decision letter by fax is requested)
If you would like to receive your decision letter by fax, enter your 10-digit fax number (XXX-XXX-XXXX). A copy of the letter will also be mailed to you.
Contact Name:
Enter the full name of the individual who can be contacted for questions regarding the prior authorization coversheet and medical records.
Contact Phone/Ext.:
Enter the 10-digit telephone number (XXX-XXX-XXXX) of the individual who can be contacted for questions regarding the prior authorization coversheet and medical records.
Requester Name:
Enter the name of the individual submitting the request. When the coversheet is completed, print, and sign the request.
Requester Phone/Ext.:
Enter the 10-digit telephone number (XXX-XXX-XXXX) of the individual who submitted the request.
Requester Signature:
Enter the signature of the individual submitting the request. When the coversheet is completed, print, and sign the request.
Date:
Provide the date the coversheet was completed in a MM/DD/YYYY format.
Note: Do not use the expedited prior authorization request unless the normal timeframe for a decision notification could jeopardize the life or health of the beneficiary. If the medical records submitted with the expedited request do not justify an expedited request, then the request will be subject to the normal process and timeframes.
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