Prior Authorization Program for Repetitive Scheduled Non-Emergent Ambulance Transport
Prior Authorization Request (PAR) Submissions Requirements
Extended Affirmation Periods for Beneficiaries with Chronic Conditions
Prior Authorization Request Submission Options
Prior Authorization Customer Services Phone Number
Background
CMS began operating the Medicare Fee-for-Service (FFS) RSNAT PA Model in New Jersey, Pennsylvania, and South Carolina on December 1, 2014, under the authority of Section 1115A of the Act. The model tested whether PA of RSNAT services covered under Medicare Part B lowered program spending, while maintaining or improving the quality of care. Section 515(a) of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) added Delaware, the District of Columbia, Maryland, North Carolina, Virginia, and West Virginia to the model on January 1, 2016.
Section 515(b) of MACRA added paragraph (16) to section 1834(l) of the Social Security Act (the Act), which required that, beginning January 1, 2017, the Secretary expand the model nationally to all states, if an expansion meets the statutory requirements for expansion of Innovation Center models described in paragraphs (1) through (3) of section 1115A(c) of the Act. After determining that the model met all statutory criteria for expansion, CMS began expanding the model through multiple phases on December 1, 2021. The model became fully operational nationwide on August 1, 2022, as the final expansion phase was implemented.
By submitting a completed coversheet and the required documentation, a supplier can receive provisional prior authorization for as many as 40 round trips (80 one-way transports) in a 60-day period.
Suppliers can use the Prior Authorization Code Lookup Tool to verify if a code is subject to the RSNAT PA. The results given by the tool will advise if the code is subject to PA.
Applicable Services, Beneficiaries, Suppliers
A repetitive ambulance service is defined as a medically necessary ambulance transportation that is furnished three or more times during a 10-day period, or at least once per week for at least 3 weeks (round trips).
The model includes the following HCPCS codes:
- A0426 - Ambulance service, advanced life support, non-emergency transport, level 1 (ALS1)
- A0428 - Ambulance service, basic life support (BLS), non-emergency transport
HCPCS code A0425 is considered an associated service and will not receive prior authorization.
Note: Ambulance suppliers under review by a unified program integrity contractor (UPIC) are not eligible to submit prior authorization requests (PARs).
General Information
| Question | Answer |
|---|---|
| Who | Ambulance service suppliers that bill Medicare Part B can receive provisional prior authorization. |
| What | Suppliers can receive prior authorization for up to 40 non-emergency scheduled round trips (HCPCS codes A0426, A0428) or 80 one-way transports in 60 days. For scheduled trips beyond the prior authorized number, a second prior authorization request is required. |
| Why | The purpose of the prior authorization program is to reduce improper payments, while maintaining or improving quality of care. It is designed to ensure all relevant coverage, coding, and medical record(s) requirements are met before the service is rendered to the beneficiary and the claim is submitted for payment. |
| How |
Submit the PAR. Attach the required medical records. Request decision notifications will be issued within seven calendar days of receipt of submission. Resubmitted 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 of the CMS 1500 (02/12) claim form or the electronic equivalent. To avoid claim payment delays and interruptions, submit initial prior authorization requests 10-15 days before the start of scheduled repetitive services and subsequent requests no later than 10 business days before the end of the current 60-day authorization period, ensuring the cover sheet's "Start Date of Authorization" reflects the start of the next period and is after the end date of the previous 60-day period. Medical record requirements determine the earliest possible submission date for a subsequent request. For example, the physician certification statement (PCS) must be valid for the requested start date and signed and dated no earlier than 60 days in advance of the requested start date. (i.e., for a requested start date of 06/23/2026, the signature date on the PCS can be no earlier than 04/24/2026. |
Coverage Policies
For more information on coverage and documentation requirements, refer to:
- 42 CFR § 410.40, Coverage of Ambulance Services
- 42 CFR § 410.41, Requirements for Ambulance Suppliers
- 42 CFR § 424.36, Signature requirements
- CMS IOM Pub. 100-02 Medicare Benefit Policy Manual, Chapter 10
- CMS IOM Pub. 100-04 Medicare Claims Processing Manual, Chapter 15
- CMS IOM Pub. 100-08 Medicare Program Integrity Manual, Chapter 3
Glossary Tool
This tool is a list of common terms used by medical review for prior authorization request:
Prior Authorization Request (PAR) Submission Requirements
Prior authorization should ideally be requested prior to rendering transports. The PAR must include all documentation necessary to show that the service meets applicable Medicare coverage, coding, and payment rules.
- Prior Authorization Request for Repetitive Non-Emergent Ambulance Medicare Part B Fax/Mail Coversheet
- Instructions for Completing the Prior Authorization Request Coversheet for Non-Emergent Ambulance Services
This form is available for submission through our secure internet portal SPOT. If you do not have a SPOT account, enrollment information is provided by accessing the learn how to register.
Prior authorization is voluntary, however if the ambulance provider elects to bypass prior authorization, First Coast will stop an applicable claim for prepayment review if submitted without a prior authorization request decision.
Documentation Requirements
To meet coverage criteria, the patient's medical record must contain documentation that fully supports the medical necessity for services.
- Ambulance Physician Certification Statement
- Prior Authorization Request Submission Checklist
- Ambulance Prior Authorization – Documentation Checklist for Medical Professionals
- Provider Documentation Tool for Non-Emergent Ambulance Transportation
- Repetitive Scheduled Non-Emergent Ambulance Transportation (RSNAT) Glossary Tool
Expedited Requests
Effective January 9, 2025, CMS will be removing the expedited review request. Refer to Change Request (CR) 13711, Repetitive, Scheduled Non-Emergent Ambulance Transport (RSNAT) Prior Authorization (PA) Model Operational Changes Regarding Expedited Requests and Review Timeframes
Extended Affirmation Periods for Beneficiaries with Chronic Conditions
MACs may now allow up to 240 one-way trips in a 180-day period per prior authorization request for beneficiaries with chronic conditions that are deemed not likely to change over time and meeting all Medicare requirements for repetitive non-emergent ambulance transport. The medical records must clearly indicate the condition is chronic. In addition, two previous prior authorizations requests must have established that the beneficiary’s medical condition has not changed or has deteriorated from previous requests before the MACs may allow an extended affirmation period.
- The decision to allow an extended affirmation period is at MAC discretion. Ambulance suppliers cannot request transports beyond the current maximum of 80 transports per 60-day period.
- Ambulance suppliers are responsible for always maintaining a valid physician certification statement (PCS).
- The MACs reserve the right to request the PCS at any time.
- Each individual time a patient is transported by ambulance, that transport must be reasonable and necessary regardless of whether a new prior authorization is required.
Claim Submission Requirements
Reminder: UTNs are required on corresponding claims – learn more
Prior Authorization Request Submission Options
The SPOT portal serves as the fastest method for submitting a Repetitive Scheduled Non-Emergent Ambulance Transport (RSNAT) Prior Authorization request and obtaining decision letters. After submitting a request through the Prior Auth feature in SPOT the letter will be available in the portal mailbox within 7 calendar days after submission. This significantly reduces the time suppliers spend waiting for their decision letter. Refer to the SPOT user guide for detailed instructions on all SPOT features. SPOT is a free online portal for providers, billing services, and clearinghouses. To request access, follow the SPOT enrollment instructions.
Fax Number:
1-855-815-3065
Mailing Address:
First Coast Service Options, Inc.
JN Prior Authorization
PO Box 3033
Mechanicsburg, PA 17055-1804
Priority Mailing Address:
First Coast Service Options, Inc.
Attention: JN Prior Authorization
2020 Technology Parkway
Suite 100
Mechanicsburg, PA 17050
Prior Authorization Customer Service Phone Number
1-855-340-5975 available Monday - Friday, 8 a.m. - 6 p.m. ET
Educational Events
Please visit our educational events calendar for all training opportunities and to register to participate in the webinars.
Quick Links and Resources
- Ambulance Prior Authorization Physician/Practitioner Letter
- MLN Fact Sheet MLN6805343, Repetitive, Scheduled Non-Emergent Ambulance Transport Prior Authorization Model
- Prior Authorization of Repetitive Scheduled Non-Emergent Ambulance Transport
- Repetitive, Scheduled Non-Emergent Ambulance Transport (RSNAT) Prior Authorization Model Frequently Asked Questions
- Repetitive, Scheduled Non-Emergent Ambulance Transport Prior Authorization Model – Operational Guide