Ambulance prior authorization documentation requirements

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Home ► Prior authorization ► Ambulance prior authorization documentation requirements

Last Modified: 3/1/2024 Location: FL, PR, USVI Business: Part B

Ambulance Prior Authorization Documentation Requirements

Background

The primary reason prior authorization requests pdf file

are non-affirmed is insufficient, incomplete, or contradictory medical record entries. Requests that do not have the required clinical assessment data and objective findings will receive a provisional non-affirmed decision.

The CMS Repetitive, Scheduled Non-Emergent Ambulance Transport Prior Authorization Model Operational Guide external pdf file

lists the required medical records. Medical records should provide sufficient information, in the form of objective findings and clinical assessment data, to support the cover sheet data and the PCS (Physician Certification Statement). A signed and dated PCS does not, by itself, demonstrate that the repetitive scheduled transports are medically necessary.

Additional required medical records

A complete request should have a completed cover sheet and the following items:

• The PCS; and

• Medical records with objective findings and clinical assessment data that provide information on the beneficiary's mobility and/or functional status and/or medical conditions listed on the PCS. The medical record must demonstrate that transportation by other means is contraindicated. Records with only vague statements, such as "patient is bed-confined" and “not safe to sit in a wheelchair”, are insufficient.

PCS

The PCS should contain information on the beneficiary's condition, to include diagnoses and a description of the beneficiary's mobility and/or functional status or medical condition(s). It must be signed and dated by the patient’s attending physician. The signature and date must be legible. Stamped signatures are not acceptable.

To be valid, the PCS cannot be dated more than 60 days in advance of the requested start date of service. For example, a PCS signed 01/01/23 would not be valid for a request with a start date of 04/15/23.

Medical records

Medical records that describe the beneficiary's mobility and/or functional status or medical conditions(s) and support the PCS can include, but are not limited to doctor's progress notes, nursing notes, physical or occupational therapy notes, history, and physical, minimum data set (MDS), hospital or facility admission and discharge summaries.

Medical records should be current for the medical condition(s) that could necessitate the transports. Medical records should be dated on or before the signature date of the PCS.

Every page of the medical record must be legible and include appropriate patient identification information (e.g., complete name, dates of service(s)). The record must include the name of the physician or non-physician practitioner responsible for and providing the care of the patient, inclusive of their signature on the medical record.

For guidelines for physicians or healthcare practitioners on medical record criteria, refer to Ambulance Prior Authorization - Documentation Checklist for Medical Professionals.

For more information on coverage and documentation requirements, refer to the following resources:

• CFR, Title 42, Chapter IV, Subchapter B, Part 410, Subpart B, Section 410.40 - Coverage of Ambulance Services external link

• CFR, Title 42, Chapter IV, Subchapter B, Part 410, Subpart B, Section 410.41- Requirements for Ambulance Suppliers external link

• CFR, Title 42, Chapter IV, Subchapter B, Part 424, Subpart C, Section 424.36 - Signature requirements external link

• CMS IOM Pub. 100-02, Medicare Benefit Policy Manual, Chapter 10 external pdf file

• CMS IOM Pub 100-04, Medicare Claims Processing Manual, Chapter 15 external pdf file

• CMS IOM Publ100-08, Medicare Program Integrity Manual, Chapter 3, section 3.3.2.4 external pdf file

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