After years of waiting the national expansion of the prior authorization model for Repetitive, Scheduled Non-Emergent Ambulance Transports (RSNAT) is upon us. For the rest of this year implementation of the prior authorization model will begin. On August 26, 2021, CMS announced the following implementation dates for all remaining states and territories. Keep in mind these dates are “no earlier than” dates. Here is the schedule:
December 1, 2021
Arkansas, Colorado, Louisiana, Mississippi, New Mexico, Oklahoma, Texas
February 1, 2022
Alabama, American Samoa, California, Georgia, Guam, Hawaii, Nevada, Northern Mariana Islands, Tennessee
April 1, 2022
Florida, Illinois, Iowa, Kansas, Minnesota, Missouri, Nebraska, Puerto Rico, Wisconsin, US Virgin Islands
June 1, 2022
Connecticut, Indiana, Maine, Massachusetts, Michigan, New Hampshire, New York, Rhode Island, Vermont
August 1, 2022
Alaska, Arizona, Idaho, Kentucky, Montana, North Dakota, Ohio, Oregon, South Dakota, Utah, Washington, Wyoming
What is Prior Authorization?
You may be familiar with prior authorization requirements with other payers, such as Medicaid or private insurance payers. This article covers the Medicare Part B RSNAT program. Prior authorization is a process where information is submitted to Medicare prior to the ambulance transport with a request for provisional approval of coverage for the service. This process helps avoid denials by filtering out services where the applicable coverage, payment, and coding rules for repetitive non-emergent ambulance transports are not met. CMS has also said that claims with prior authorization are protected from “most future audits.” However, receiving a prior authorization does not mean the claim will ultimately be covered. Other program coverage requirements, such as medical necessity, must still be met.
What Types of Transports Does RSNAT Apply To?
The RSNAT prior authorization program is limited in scope. It does not apply to institutional/hospital-based ambulance services, transports included in a Part A bundled payment, or ambulance suppliers under a Unified Program Integrity Contractor (UPIC). RSNAT only applies to independent ambulance suppliers billing under Part B.
Assuming your service is one of the participants, only the following HCPCS codes are subject to prior authorization:
A0426 – ALS, Non-Emergency
A0428 – BLS, Non-Emergency
The mileage code (A0425) does not require prior authorization and is paid when the above codes are covered.
Lastly, RSNAT only applies to scheduled, repetitive transports. This means transports for continuing repetitive services like dialysis or wound care. As a reminder, CMS defines repetitive as:
- ambulance trips that are furnished either 3 or more times during a 10-day period; or
- ambulance trips furnished at least once per week for at least three weeks.
How Prior Authorization Will Work
First, Ambulance suppliers (or the beneficiary) will submit a prior authorization request to their MAC. The request can be mailed, faxed, submitted through the MAC provider portal, or submitted through the CMS Electronic Submission of Medical Documentation (esMD) system here.
The request will use a newly created cover sheet developed by CMS and dispersed by the MACs. These sheets will contain beneficiary information, certifying physician information, ambulance supplier information, and other information about the number of transports and level of service provided. Here are two examples of the Cover Sheet:
Attached to this cover sheet, the ambulance supplier will include all required documents to support the transport. These include: PCS, medical record documents to support medical necessity, information on the origin and destination of the transports, and any other relevant documents requested by the MAC (on-site assessments, previous PCRs, other medical records and notes).
Once received, the MAC will notify the supplier and beneficiary within 10 business days (for both initial and resubmitted requests). In urgent situations you can submit a request for expedited review and the MAC will make reasonable efforts to provide a decision within 2 business days. If an initial request is denied, the supplier may resubmit the request with additional documents an unlimited number of times.
Affirmative Decisions
If the prior authorization receives provision affirmation, the supplier will be provided with a Unique Tracking Number (UTN). This number is very important and must be submitted with each claim for the repetitive transports. Keep in mind the UTN does not follow the patient. So, if another supplier has obtained a UTN for the same patient’s repetitive transports, that supplier must first cancel their UTN so the new supplier can request a new UTN and begin transporting the patient. For this reason, we highly recommend determining whether another UTN exists for a patient and working with the previous supplier to cancel it as part of your intake process.
Non-Affirmative Decisions
If the prior authorization is denied, the supplier has the following options:
- Resubmit the request for prior authorization with additional documentation;
- Bill the claim with the non-affirmative UTN and receive a denial. In this case, bill the secondary payer if one exists;
- Obtain ABNs on future transports with the patient to assist with billing the patient directly once appeals for denied claims are exhausted.
If the supplier decides not to seek a prior authorization, they can bill the claim as normal and it will be subject to pre-payment review.
What Does the Ideal Process Look Like?
Ideally, the supplier should submit the prior authorization request before it renders the repetitive transports. Keep in mind, Medicare permits the first three round trips without a prior authorization. Therefore, during this time the supplier should be collecting all required documents and making the request. We recommend all suppliers develop a policy and procedure for handling RSNAT prior authorization transports. Let us know if we can help you with that!
CMS has provided a letter to providers and other entities here to help ensure your service can obtain the required documents and help set expectations with your patient care partners going forward.
Here is an operational guide provided by CMS to assist your service with the details of the RSNAT Prior Authorization program.
Conclusion
RSNAT will add additional work on the front-end for your service to get repetitive transports processed and paid with the trade-off of more certainty that claims will be properly paid and protected from audit. We recommend you keep in contact with your MAC for information as your implementation date nears. Having a policy/procedure in place to obtain the proper documents and submit the requests in a timely manner will help your service avoid setbacks in payment. Finally, good communication with your local providers sets proper expectations and keeps open the lines of communication to receive the necessary documents from the correct people.
We’re here to help! If your service needs assistance developing a plan to meet these new requirements contact us! We assist with developing policies and procedures, QA, and will help advocate for you with other providers and facilities.