Prior authorization program for repetitive scheduled non-emergent ambulance transports
Background
CMS began operating the repetitive scheduled non-emergent ambulance transports (RSNAT) prior authorization (PA) program in limited states in 2014 under the authority of the Social Security Act. In subsequent years, the Medicare Access and CHIP Reauthorization Act of 2015 required that the model expand to all states if such an expansion met certain criteria outlined in the Act. The model has met all nationwide criteria, and CMS has received final approval to expand the model nationwide. In April 2022, this program was implemented for providers in First Coast’s jurisdiction:
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.
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).
Submissions
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 RSNAT coversheet
Note: This form is available for submission through our secure internet portal SPOT. If you do not have a SPOT account, 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.
Expedited requests
Note: Effective January 9, 2025, CMS will be removing the expedited review request. Refer to Change Request (CR) 13711 for complete details on the change.
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 tips
- Prior authorization for ambulance transports is for repetitive transports
- View claim submission guidelines for RSNAT services
Reminder: UTNs are required on corresponding claims – learn more
Prior authorization request submission options
The Secure Provider Online Tool (SPOT) serves as the fastest method for submitting a prior authorization request and obtaining decision letters.
Ambulance suppliers can expect to find their decision letter in their portal mailbox within seven 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.
Quick links
- Prior authorization of repetitive scheduled non-emergent ambulance transport
- Repetitive, Scheduled Non-Emergent Ambulance Transport Prior Authorization Model – Operational Guide
- Ambulance prior authorization FAQs
- National Expansion of the Repetitive Scheduled Non-Emergent Ambulance Transport (RSNAT) Prior Authorization Model
- CMS Letter to Ambulance Suppliers
- Physician/Practitioner Letter
- Medicare Program; National Expansion Implementation for All Remaining States and Territories of the Prior Authorization Model for Repetitive, Scheduled Non-Emergent Ambulance Transports
General information
| Question |
Answer |
|---|---|
| Who |
Ambulance service suppliers that bill Medicare Part B can receive provisional prior authorization in JN (Florida, Puerto Rico and U.S. Virgin Islands) |
| 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. |
| When |
Effective March 18, 2022, CMS will prior authorize certain repetitive scheduled non-emergent ambulance transports for dates of service on or after April 1, 2022, in Florida, Puerto Rico and the USVI. |
| Where |
Ambulance suppliers garaged in Florida, Puerto Rico and U.S. Virgin Islands. |
| 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. Note: Effective January 9, 2025, request decision notifications will be issued within 7 calendar days. Refer to Change Request (CR) 13711 for complete details on the change. |
Upcoming events
Please visit our educational events calendar for all currently available training opportunities.
Additional education opportunities
View these videos related to ambulance services:
Documentation
To meet coverage criteria, the patient's medical record must contain documentation that fully supports the medical necessity for services.
- Repetitive scheduled non-emergent ambulance transportation (RSNAT) glossary tool
- Ambulance prior authorization documentation requirements
- Prior authorization request submission checklist
- Ambulance prior authorization – Documentation checklist for medical professionals
- Provider documentation tool for non-emergent ambulance transportation
- Ambulance physician certification statement
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
- CFR, Title 42, Chapter IV, Subchapter B, Part 410, Subpart B, Section 410.41- Requirements for Ambulance Suppliers
- CFR, Title 42, Chapter IV, Subchapter B, Part 424, Subpart C, Section 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 Publ100-08, Medicare Program Integrity Manual, Chapter 3, section 3.3.2.4
PA contact information
Prior authorization customer service phone number: 1-855-340-5975
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
View additional information regarding prior authorization for repetitive scheduled non-emergent ambulance transports.