Extension of Prior Authorization for Repetitive, Scheduled Non-Emergent Ambulance Transports

Federal Register announced in their notice that a 1-year extension of the Medicare Prior Authorization Model for Repetitive Scheduled Non-Emergent Ambulance Transport. The extension of this model is applicable in certain states only. Earlier in those states, ambulance suppliers must obtain prior authorization from Medicare before providing scheduled, non-emergency ambulance transportation.

These states are:

  • Delaware
  • District of Columbia
  • Maryland
  • New Jersey
  • North Carolina
  • Pennsylvania
  • South Carolina
  • Virginia
  • West Virginia

Medicare may provide cover for ambulance services, including air ambulance services if the ambulance service is furnished to a beneficiary whose medical condition is such that other modes of transportation are contraindicated. The beneficiary’s condition must require both the ambulance transportation itself and the level of service provided in order for the billed service to be considered medically necessary.

Repetitive Ambulance Service

This extension started last year December and ends on December 1, 2020. A repetitive ambulance service is defined as medically necessary ambulance transportation that is furnished in 3 or more round trips during a 10-day period or at least 1 round trip per week for at least 3 weeks.[2] Repetitive ambulance services are often needed by beneficiaries receiving dialysis or cancer treatment.

Medicare may cover repetitive, scheduled non-emergent transportation by ambulance if the,

  • Medical necessity requirements described previously are met; and
  • The ambulance provider/supplier, before furnishing the service to the beneficiary, obtains a written order from the beneficiary’s attending physician certifying that the medical necessity requirements are met (see 42 CFR 410.40 (d)(1) and (2)).

Assistance with Alternative Transportation Resources

According to CMS, Medicare beneficiaries who do not qualify for coverage of repetitive, scheduled non-emergent ambulance transportation under the Medicare benefit are encouraged to check into other services:

  • Medicare beneficiaries who receive a non-affirmed prior authorization decision letter can call Fed Pro Services, LLC at 1-888-855-0542 for assistance until July 17, 2020, when this Medicare service ends. TTY users should call 1-855-200-0763. Customer service representatives will discuss beneficiaries’ transportation needs and direct them to the most appropriate transportation resources in their area.
  • Medicare beneficiaries can ask other programs that they may be a part of, like Medicaid or Programs of All-inclusive Care for the Elderly (PACE) if they qualify for their help with transportation coverage.
  • Medicare beneficiaries can also contact Eldercare at 1-800-677-1116 or their local State Health Insurance Assistance Program to ask about other state and local services that can help.

COVID-19 Pandemic Update

The testing of the Medicare Prior Authorization Model for Repetitive, Scheduled Non‑Emergent Ambulance Transport under section 1115A of the Social Security Act (the Act) is being extended in the current model states of Delaware, the District of Columbia, Maryland, New Jersey, North Carolina, Pennsylvania, South Carolina, Virginia, and West Virginia for one additional year while CMS continues to work towards nationwide expansion under section 1834(l)(16) of the Act. You can see more information about this notice on the Federal Register Gov Website.

The prior authorization process under the extension of the model under 1115A authority will continue to apply in the nine states listed previously for the following codes for Medicare payment:

  • A0426: Ambulance service, advanced life support, non-emergency transport, Level 1 (ALS1).
  • A0428: Ambulance service, BLS, non-emergency transport.

While prior authorization is not needed for the mileage code, A0425, a prior authorization decision for an A0426 or A0428 code will automatically include the associated mileage code.

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