Repetitive scheduled non-emergency ambulance transport prior authorization claims submission guidelines

Prior authorization process

• First Coast will send a decision letter to the ambulance supplier and the beneficiary
• The decision letter will include the prior authorization unique tracking number (UTN) that must be submitted on the claims
• A UTN will be issued for approved and non-approved prior authorization requests

UTN requirements

• Required on claims that have been through the prior authorization process
• Prior authorization is only on repetitive, scheduled non-emergency ambulance transports
• If the service being submitted has not been through the prior authorization process, you shouldn’t submit a UTN on your claim. 

Note: If the transport submitted is not a repetitive service the assigned UTN should not be submitted on your claim.

Claim requirements

ASC X12 837P

• Report in 2300, the claim information loop, or 2400, the service line loop
• Prior Authorization Reference (REF) segments
  •  REF01 = “G1” qualifier
  • REF02 = UTN

Paper claim form

• Report in the first 14 positions in Item 23 of the 1500 claim form
• All other data submitted must begin in position 15.

Note: If you have a UTN for a beneficiary, and you submit a claim for a repetitive transport for that beneficiary without the UTN, the claim will reject. You will have to resubmit the claim with the UTN.