Prior Authorization of Repetitive, Scheduled Non-Emergent Ambulance Transport

Spending and Affirmation Rate Results 11/18/2020

The Centers for Medicare & Medicaid Services (CMS) is releasing updated spending and affirmation rates from the first five years of the Prior Authorization Model for Repetitive, Scheduled Non-Emergent Ambulance Transport. Please see the Status Update in the "Downloads" section below.

CMS to Expand Model Nationwide

CMS recently announced that it will expand the Repetitive, Scheduled Non-Emergent Ambulance Transport (RSNAT) Prior Authorization Model nationwide, as the model has met all expansion criteria under section 1834(l)16 of the Social Security Act (the Act) (as added by section 515(b) of the Medicare Access and CHIP Reauthorization Act of 2015 (Pub. L. 114-10) (MACRA).   

CMS also released the model’s Second Interim Evaluation Report. The report found that the model was successful in reducing RSNAT services and total Medicare spending while maintaining overall quality of and access to care levels. 

The Chief Actuary of CMS certified in March 2018 that nationwide expansion of the model would reduce net program spending under the Medicare program. 

Based on the Chief Actuary certification and Interim Evaluation Reports, the Secretary of Health and Human Services determined that the model met the statutory criteria for expansion under sections 1115A(c)(1) and (c)(3) of the Social Security Act (the Act). CMS is therefore required under section 1834(l)(16) of the Act, as added by section 515(b) of MACRA (Pub. L. 114-10), to expand the model nationwide. 

The model will continue without interruption in the current states of Delaware, the District of Columbia, Maryland, New Jersey, North Carolina, Pennsylvania, South Carolina, Virginia, and West Virginia beyond December 1, 2020, when the model was previously scheduled to end. Due to the COVID-19 Public Health Emergency, CMS is delaying the implementation of the expansion to additional states at this time. CMS will continue to monitor the Public Health Emergency and will provide public notice before implementing the model in additional states.

The national model will follow the same design as the current model (as tested by the CMS Center for Medicare and Medicaid Innovation under section 1115A of the Act). Please see the November 20 notice for more details.

Resumption of Model Activities Update 07/07/2020

Given the importance of prior authorization activities to CMS’ program integrity efforts, CMS will discontinue exercising enforcement discretion for the Repetitive, Scheduled Non-Emergent Ambulance Transport Prior Authorization Model beginning on August 3, 2020, regardless of the status of the public health emergency (see additional information here (PDF)). Effective for claims submitted on or after August 3, 2020, CMS will resume full model operations including prepayment review if prior authorization has not been requested by the fourth round trip in a 30-day period.

Following resumption of the model, the Medicare Administrative Contractors will conduct postpayment review on claims that were subject to the model that were submitted and paid during the pause without prior authorization. CMS will post more information on the postpayment review process in the near future.

Assistance with Alternative Transportation Resources 06/30/2020

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. For more information, visit www.FedPro.net.
  • 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 03/31/2020

On March 30, 2020, CMS announced a pause of certain claims processing requirements for the Prior Authorization Model for Repetitive, Scheduled Non-Emergent Ambulance Transport in the model states of Delaware, the District of Columbia, Maryland, New Jersey, North Carolina, Pennsylvania, South Carolina, Virginia, and West Virginia until the Public Health Emergency for the COVID-19 pandemic has ended.  Please see here (PDF) for more information.

Spending and Affirmation Rate Results 11/08/2019

CMS is releasing updated spending and affirmation rates from the first four years of the Prior Authorization Model for Repetitive, Scheduled Non-Emergent Ambulance Transport. Please see the Status Update in the "Downloads" section below.

1-Year Extension Update 09/13/2019

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. The existing testing of the model under section 1115A authority is currently scheduled to end in all states on December 1, 2019; however, a Federal Register notice extends the model under the authority in section 1115A of the Act through December 1, 2020.

Spending and Affirmation Rate Results 10/26/2018

CMS is releasing updated spending and affirmation rates from the first three years of the Prior Authorization Model for Repetitive, Scheduled Non-Emergent Ambulance Transport. Please see the Status Update in the "Downloads" section below.

Spending and Evaluation Results 02/12/2018

CMS is releasing spending and affirmation rates from the first two years of the Prior Authorization Model for Repetitive, Scheduled Non-Emergent Ambulance Transport. Please see the Status Update in the "Downloads" section below.

An evaluation of the model is also being conducted as required by Section 1115A of the Social Security Act. CMS released the First Interim Evaluation Report of the Medicare Prior Authorization Model for Repetitive Scheduled Non-Emergent Ambulance Transport. Please see the Ambulance Prior Authorization Model First Interim Evaluation Report in the “Related Links” section below.

1-Year Extension Update 12/04/2017

The Medicare Prior Authorization Model for Repetitive, Scheduled Non‑Emergent Ambulance Transport 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 to allow for additional evaluation of the model. The model is currently scheduled to end in all states on December 1, 2018.

In the model States, repetitive, scheduled non-emergent ambulance transport claims with dates of service of December 2, 2017 through December 4, 2017 will not be stopped for prepayment review if prior authorization is not requested before the fourth round trip in a 30-day period; however, providers may request prior authorization for these dates of service. All repetitive, scheduled non-emergent ambulance transports in the model States with a date of service on or after December 5, 2017 must have completed the prior authorization process or the subsequent claims will be stopped for prepayment review if prior authorization has not been requested before the fourth round trip in a 30-day period.

Nationwide Expansion Update 10/21/2016

The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) expands the Prior Authorization Model for Repetitive, Scheduled Non-Emergent Ambulance Transport to all states if the model meets certain requirements. CMS is currently exploring the nationwide expansion to determine if all requirements specified in MACRA have been met.

If expansion occurs, there will be advance notice and training opportunities, as appropriate. CMS will continue to update this website as more information becomes available.

Background

CMS is implementing a prior authorization model for repetitive, scheduled non-emergent ambulance transports to test whether prior authorization helps reduce expenditures, while maintaining or improving access to and quality of care. CMS believes using a prior authorization process will help ensure services are provided in compliance with applicable Medicare coverage, coding, and payment rules before services are rendered and claims are paid.

Prior authorization does not create new clinical documentation requirements. Instead, it requires the same information that is already required to support Medicare payment, just earlier in the process. Prior authorization allows providers and suppliers to address issues with claims prior to rendering services and submitting claims for payment, which has the potential to reduce appeals for claims that may otherwise be denied. This will help ensure that all relevant coverage, coding, and payment requirements are met before the service is rendered to the beneficiary and before the claim is submitted for payment.

Phase I

Ambulance suppliers or beneficiaries began submitting prior authorization requests in South Carolina, New Jersey and Pennsylvania on December 1, 2014, for transports occurring on or after December 15, 2014. All repetitive, scheduled non-emergent ambulance transports in these states with a date of service on or after December 15, 2014, must have completed the prior authorization process or the claims will be stopped for prepayment review if prior authorization has not been requested by the fourth round trip in a 30-day period.

Phase II

Section 515 of MACRA included six additional areas in the model effective no later than January 1, 2016: Delaware, the District of Columbia, Maryland, North Carolina, Virginia, and West Virginia.

Ambulance suppliers or beneficiaries in Delaware, the District of Columbia, Maryland, North Carolina, Virginia, and West Virginia began submitting prior authorization requests on December 15, 2015, for transports occurring on or after January 1, 2016. All repetitive scheduled non-emergent ambulance transports in these areas with a date of service on or after January 1, 2016, must have completed the prior authorization process or the claims will be stopped for pre-payment review if prior authorization has not been requested by the fourth round trip in a 30-day period.

Helpful Educational Documents

  • A letter ambulance suppliers can share with physicians and other entities to help obtain the necessary documentation in a timely manner can be found in the Downloads section below.
  • For more operational details about the Prior Authorization of Repetitive, Scheduled Non-Emergent Ambulance Transport model, please see the Ambulance Prior Authorization Operational Guide in the ‘Downloads’ section below.

Questions can be sent to: AmbulancePA@cms.hhs.gov.

For additional information please refer to the link and download sections below.

Page Last Modified:
11/20/2020 12:11 PM