Subsequent requests

More than 60 days of transport

To avoid payment interruptions, submit the subsequent prior authorization request no later than 10 business days before the end of the 60-day period. On the coversheet, in the 'Start Date of Authorization' field, specify the start date of the next period. Ensure that date is after the end of the prior 60-day period.

One affirmed UTN is assigned to the beneficiary for up to 40 round trips (or 80 transports) by one supplier per 60-day period. If there is a need for transports beyond 40 round trips, submit a subsequent prior authorization request along with medical records that explains the needs of the beneficiary.

Dialysis and chemotherapy 

Ambulance suppliers should not get two prior authorizations (PA) if a beneficiary needs dialysis and chemotherapy. The provisional affirmation decision and unique tracking number (UTN) will prior authorize up to 40 round trips in a 60-day period. Regardless of the treatment sought at the destination, if the transports are medically necessary, as supported by the medical records, and are repetitive and scheduled, they are provisionally prior authorized under the UTN. Because these transports are repetitive and scheduled, the supplier should know the number of transports planned for a 60-day period. The maximum number of round trips allowed per 60-day period is 40 (80 transports).

When to submit

Medical record requirements determine the earliest possible submission date for a subsequent request. 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. For example, for a requested start date of June 23, 2023, the signature date on the PCS can be no earlier than April 24, 2023. 

Find additional information under Medical records and the PCS.

Coversheets

To facilitate the PA process, suppliers are encouraged to complete the coversheet in its entirety. 

Use a new coversheet for each request, including resubmissions. 

Third party requests

Prior authorization requests may be submitted by a third party for a beneficiary on behalf of a supplier. In this case, the contact name, contact phone number, and contact fax number and email fields on the coversheet should contain the information of the third party.

However, we cannot discuss a beneficiary with the third party unless the third party has a valid authorization from the beneficiary.

UTNs

There are no limits on how many times a specific beneficiary can get a UTN. However, the beneficiary gets one affirmed UTN assigned for transports by one supplier per 60-day period. One affirmed UTN is assigned to the beneficiary for up to 40 round trips (or 80 transports) by one supplier per 60-day period. If there is a need for transports beyond 40 round trips, submit a subsequent PAR along with medical records that explains the needs of the beneficiary.

Switching suppliers 

The assigned UTN is to the beneficiary for transports by one supplier, per requested timeframe.

If the beneficiary wants to switch suppliers, then the beneficiary should contact the supplier with the assigned UTN and request the UTN to be expired. The supplier then would call 855-340-5975 and cancel the UTN.

If a supplier ceases to transport a beneficiary before the UTN expires, that supplier can call 855-340-5975 and cancel the UTN. Afterwards another supplier can submit a request for prior authorization for the beneficiary.

Substitutions

Another supplier may perform a transport if authorization is given or at times the primary supplier is unavailable. 

If a supplier does not have a PA, then the supplier would file the claim and a letter requesting additional documentation will be sent for the claim to be medically reviewed before payment.

Existing PA

When substitutions or switches are made, confirm with the beneficiary if there's an existing PA for another company. The beneficiary will receive a decision notification, which will include the UTN. Also, you may submit a PA request (PAR) and receive a decision letter stating the beneficiary already has an existing UTN for requested dates of service.

Canceling a PA

A supplier cannot cancel a UTN for another supplier. If a second supplier determines a beneficiary needs another UTN, that supplier should submit a prior authorization request including a request coversheet along with a PCS and supporting medical records and attach a statement explaining the situation.

Non-repetitive transports

Non-repetitive transport services (e.g., a return trip after an emergency room visit) are not subject to PA.

We could conduct prepayment reviews on any ambulance claims, including claims for non-repetitive transports, for any beneficiary determined to be a recipient of repetitive ambulance services.

Prepayment review 

By provisionally non-affirming a request, we have determined that ambulance transports have not been proven medically necessary. Therefore, non-repetitive transport claims for beneficiaries with a non-affirmed UTN on file could be subject to prepayment medical review.

We may conduct prepayment reviews on any ambulance claims, to include claims for non-repetitive transports, for any beneficiary determined to be a recipient of repetitive ambulance services.