Repetitive scheduled non-emergent ambulance transport prior authorization request submission checklist
Submission of the following items facilitates the processing of initial or resubmission requests.
Coversheet - Optional
(Optional: The coversheet is recommended as it includes the basic information that is required to initiate your prior authorization request)
| Check | Requirement |
|---|---|
| Coversheet is complete and all entries are readable. | |
| The requestor name is printed above the signature. | |
| The date is the date the sheet was completed and signed. |
Physician certification statement (PCS) - Required
| Check | Requirement |
|---|---|
| The PCS is complete and readable. | |
| The PCS is completed, signed, and dated by the attending physician. | |
| The signature date is (no more than 60 days) prior to the requested start date. | |
| The name is printed by the signature. | |
| Credentials (such as MD or DO) of the signor are printed by or near the signature and are readable. (Dr. is a title and not a credential.) | |
| Medical conditions listed on the PCS support a non-emergent ambulance transport and are supported by the attached medical records. |
Medical records - Required
| Check | Requirement |
|---|---|
| Medical records are generated by a medical professional certified by the state on or during a date of service. Sources include, but are not limited to, doctor's progress notes, nursing notes, physical or occupational therapy notes, history and physical, MDS (minimum data set). The records should be from the beneficiary's clinician and not the ambulance supplier. | |
| Each page of the record identifies the beneficiary, the medical professional, and the date of service. | |
| The record supports the items listed on the PCS. | |
| The record supports the beneficiary's condition at the time of transport. | |
| The record describes the medical necessity of the type and level of transport services by documenting the "what" and "why" of the beneficiary's condition(s). | |
| The record was generated on or before the completion and signature date on the PCS. | |
| Every page of the record is readable. | |
| The record lists the exact origin and destination street addresses. | |
|
The record is not an attestation statement and/or the PCS.
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