Medicare Program; Prior Authorization of Repetitive Scheduled Nonemergent Ambulance Transports

Marilyn Tavenner
Department of Health & Human Services
November 14, 2014

[Federal Register Volume 79, Number 220 (Friday, November 14, 2014)]
[Notices]
[Pages 68271-68273]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 2014-26987]



[[Page 68271]]

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

[CMS-6063-N]


Medicare Program; Prior Authorization of Repetitive Scheduled 
Nonemergent Ambulance Transports

AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.

ACTION: Notice.

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SUMMARY: This notice announces a 3-year Medicare Prior Authorization 
model for repetitive scheduled nonemergent ambulance transport in the 
states of New Jersey, Pennsylvania, and South Carolina where there have 
been high incidences of improper payments for these services.

DATES: This model will begin on December 1, 2014 in South Carolina, New 
Jersey, and Pennsylvania.

FOR FURTHER INFORMATION CONTACT: Angela Gaston, (410) 786-7409. 
Questions regarding the Medicare Prior Authorization Model for 
Repetitive Scheduled Nonemergent Ambulance Transport should be sent to 
AmbulancePA@cms.hhs.gov.

SUPPLEMENTARY INFORMATION:

I. Background

    Medicare covers ambulance services, including air ambulance (fixed 
wing and rotary wing) services, when furnished to a beneficiary whose 
medical condition is such that other means 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.
    Nonemergent transportation by ambulance is appropriate if either--
(1) the beneficiary is bed-confined and it is documented that the 
beneficiary's condition is such that other methods of transportation 
are contraindicated; or (2) the beneficiary's medical condition, 
regardless of bed confinement, is such that transportation by ambulance 
is medically required. Thus, bed confinement is not the sole criterion 
in determining the medical necessity of nonemergent ambulance 
transportation; rather, it is one factor that is considered in medical 
necessity determinations.\1\
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    \1\ 42 CFR 410.40(d)(1).
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    A repetitive ambulance service is defined as medically necessary 
ambulance transportation that is furnished in 3 round trips or more 
times during a 10-day period, or at least once per week for at least 3 
weeks.\2\ Repetitive ambulance services are often needed by 
beneficiaries receiving dialysis, wound care, or cancer treatment.
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    \2\ Program Memorandum Intermediaries/Carriers, Transmittal AB-
03-106.
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    Medicare may cover repetitive, scheduled, nonemergent 
transportation by ambulance if--(1) the medical necessity requirements 
described previously are met; and (2) 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)).\3\
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    \3\ Per 42 CFR 410.40(d)(2), the physician's order must be dated 
no earlier than 60 days before the date the service is furnished.
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    In addition to the medical necessity requirements, the service must 
meet all other Medicare coverage and payment requirements, including 
requirements relating to the origin and destination of the 
transportation, vehicle and staff, and billing and reporting. 
Additional information about Medicare coverage of ambulance services 
can be found in 42 CFR 410.40, 410.41, and in the Medicare Benefit 
Policy Manual, Chapter 10, at http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c10.pdf.
    According to a study published by the Government Accountability 
Office in October 2012, entitled ``Costs and Medicare Margins Varied 
Widely; Transports of Beneficiaries Have Increased'', the number of 
Basic Life Support (BLS) nonemergent transports for Medicare fee-for-
service beneficiaries increased by 59 percent from 2004 to 2010. A 
similar finding published by the Department of Health and Human 
Services Office of Inspector General in a 2006 study, entitled 
``Medicare Payments for Ambulance Transports'', indicated a 20 percent 
nationwide improper payment rate for nonemergent ambulance transport. 
Likewise, in June 2013, the Medicare Payment Advisory Commission 
published a report \4\ that included an analysis of nonemergent 
ambulance transports to dialysis facilities and found that, during the 
5-year period between 2007 and 2011, the volume of transports to and 
from a dialysis facility increased 20 percent, more than twice the rate 
of all other ambulance transports combined.
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    \4\ Medicare Payment Advisory Commission, June 2013, pages 167-
193.
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    Section 1115A of the Act authorizes the Secretary to test 
innovative payment and service delivery models to reduce program 
expenditures, while preserving or enhancing the quality of care 
furnished to Medicare, Medicaid and Children's Health Insurance Program 
beneficiaries.
    Section 1115A(d)(1) of the Act authorizes the Secretary to waive 
such requirements of Titles XI and XVIII and of sections 1902(a)(1), 
1902(a)(13), and 1903(m)(2)(A)(iii) of the Act as may be necessary 
solely for purposes of carrying out section 1115A of the Act with 
respect to testing models described in section 1115A(b) of the Act. For 
these models, consistent with this standard, we will waive such 
provisions of sections 1834(a)(15) and 1869(h) of the Act that limit 
our ability to conduct prior authorization. While these provisions are 
specific to durable medical equipment and physician services, we will 
waive any portion of these sections as well as any portion of 42 CFR 
410.20(d), which implements section 1869(h) of the Act, that could be 
construed to limit our ability to conduct prior authorization. We have 
determined that the implementation of this model does not require the 
waiver of any fraud and abuse law, including sections 1128A, 1128B, and 
1877 of the Act. Thus, providers and suppliers affected by this model 
must comply with all applicable fraud and abuse laws.

II. Provisions of the Notice

    We plan to implement a 3-year Medicare Prior Authorization process 
for repetitive scheduled nonemergent ambulance transport rendered by 
ambulance providers/suppliers garaged in 3 states (New Jersey, 
Pennsylvania, and South Carolina). These states were selected as the 
initial states for the model because of their high utilization and 
improper payment rates for these services. The model will begin in on 
December 1, 2014, in South Carolina, New Jersey, and Pennsylvania.
    We plan to test whether prior authorization helps reduce 
expenditures, while maintaining or improving quality of care, using a 
model that would establish a prior authorization process for repetitive 
scheduled nonemergent ambulance transport to reduce utilization of 
services that do not comply with Medicare policy.
    We plan to use this prior authorization process to ensure that all 
relevant clinical or medical documentation requirements are met before 
services are rendered to beneficiaries and before claims are

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submitted for payment. This prior authorization process will further 
ensure that payment complies with Medicare documentation, coverage, 
payment, and coding rules.
    The use of prior authorization will not create new clinical 
documentation requirements. Instead, it will require 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.
    The prior authorization process under this model will be available 
for the following codes for Medicare payment:
     A0425 Ambulance service, basic life support (BLS)/advanced 
life support (ALS) ground mileage (per statute mile).
     A0426 Ambulance service, advanced life support, 
nonemergency transport, Level 1 (ALS1).
     A0428 Ambulance service, basic life support (BLS), 
nonemergency transport.
    Prior to the start of the model, we will conduct (and thereafter 
will continue to conduct) outreach and education to ambulance 
providers/suppliers, as well as beneficiaries, through such methods as 
open door forums, frequently asked questions (FAQs) on our Web site, 
other Web site postings, and educational materials issued by the 
Medicare Administrative Contractors (MACs). Additional information 
about the implementation of the prior authorization model is available 
on the CMS Web site at http://go.cms.gov/PAAmbulance.
    Under this model, an ambulance provider/supplier or beneficiary 
will be encouraged to submit to the MAC a request for prior 
authorization along with all relevant documentation to support Medicare 
coverage of a repetitive scheduled nonemergent ambulance transport. 
Submitting a prior authorization request will be voluntary. (However, 
if prior authorization has not been requested before the fourth round 
trip in a 30-day period, the claims will be stopped for pre-payment 
review).
    In order to be provisionally affirmed, the request for prior 
authorization must meet all applicable rules and policies, and any 
local coverage determination (LCD) requirements for ambulance transport 
claims. A provisional affirmation is a preliminary finding that a 
future claim submitted to Medicare for the service likely meets 
Medicare's coverage, coding, and payment requirements. After receipt of 
all relevant documentation, the MACs will make every effort to conduct 
a review and postmark the notification of their decision on a prior 
authorization request within 10 business days for an initial 
submission. Notification will be provided to the ambulance provider/
supplier and to the beneficiary. If a subsequent prior authorization 
request is submitted after a nonaffirmative decision on an initial 
prior authorization request, the MACs will make every effort to conduct 
a review and postmark the notification of their decision on the request 
within 20 business days.
    An ambulance provider/supplier or beneficiary may request an 
expedited review when the standard timeframe for making a prior 
authorization decision could jeopardize the life or health of the 
beneficiary. If the MAC agrees that the standard review timeframe would 
put the beneficiary at risk, the MAC will make reasonable efforts to 
communicate a decision within 2 business days of receipt of all 
applicable Medicare-required documentation. As this model is for 
nonemergent services only, we expect requests for expedited reviews to 
be extremely rare.
    A provisional affirmative prior authorization decision may affirm a 
specified number of trips within a specific amount of time. The prior 
authorization decision, justified by the beneficiary's condition, may 
affirm up to 40 round trips (which equates to 80 one-way trips) per 
prior authorization request in a 60-day period. Alternatively, a 
provisional affirmative prior authorization decision may affirm less 
than 40 round trips in a 60-day period, or may affirm a request that 
seeks to provide a specified number of transports (40 round trips or 
less) in less than a 60-day period. A provisional affirmative decision 
can be for all or part of the requested number of trips. Transports 
exceeding 40 round trips (or 80 one-way trips) in a 60-day period will 
require an additional prior authorization request.
    The following describes examples of various prior authorization 
scenarios:
     Scenario 1: When an ambulance provider/supplier or 
beneficiary submits a prior authorization request to the MAC with 
appropriate documentation and all relevant Medicare coverage and 
documentation requirements are met for the ambulance transport, the MAC 
will send a provisional affirmative prior authorization decision to the 
ambulance provider/supplier and to the beneficiary. When the claim is 
submitted to the MAC by the ambulance provider/supplier, it is linked 
to the prior authorization via the claims processing system and the 
claim will be paid so long as all Medicare coding, billing, and 
coverage requirements are met. However, after submission, the claim 
could be denied for technical reasons, such as the claim was a 
duplicate claim or the claim was for a deceased beneficiary. In 
addition, a claim denial could occur since certain documentation, such 
as the trip record, needed in support of the claim cannot be reviewed 
on a prior authorization request.
     Scenario 2: When an ambulance provider/supplier or 
beneficiary submits a prior authorization request, but all relevant 
Medicare coverage requirements are not met, the MAC will send a 
nonaffirmative prior authorization decision to the ambulance provider/
supplier and to the beneficiary, advising them that Medicare will not 
pay for the service. The provider/supplier or beneficiary may then 
resubmit the request with documentation showing that Medicare 
requirements have been met. Alternatively, an ambulance provider/
supplier could render the service, and submit a claim with a 
nonaffirmative prior authorization tracking number, at which point the 
MAC would deny the claim. The ambulance provider/supplier and/or the 
beneficiary would then have the Medicare denial for secondary insurance 
purposes and would have the opportunity to submit an appeal of the 
claim denial if they believe Medicare coverage was denied 
inappropriately.
     Scenario 3: When an ambulance provider/supplier or 
beneficiary submits a prior authorization request with incomplete 
documentation, a detailed decision letter will be sent to the ambulance 
provider/supplier and to the beneficiary, with an explanation of what 
information is missing. The ambulance provider/supplier or beneficiary 
can rectify the situation and resubmit the prior authorization request 
with appropriate documentation.
     Scenario 4: When an ambulance provider or supplier renders 
a service to a beneficiary that is subject to the prior authorization 
process, and the claim is submitted to the MAC for payment without 
requesting a prior authorization, the claim will be stopped for 
prepayment review and documentation will be requested.
    ++ If the claim is determined to be not medically necessary or to 
be insufficiently documented, the claim will be denied, and all current 
policies and procedures regarding liability for payment will apply. The 
ambulance provider/supplier or the beneficiary or both can appeal the 
claim denial if they believe the denial was inappropriate.
    ++ If the claim is determined to be payable, it will be paid.
    Under the model, we will work to limit any adverse impact on

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beneficiaries and to educate beneficiaries about the process. If a 
prior authorization request is not affirmed, and the claim is still 
submitted by the provider/supplier, the claim will be denied in full, 
but beneficiaries will continue to have all applicable administrative 
appeal rights.
    Only one prior authorization request per beneficiary per designated 
time period can be provisionally affirmed. If the initial provider/
supplier cannot complete the total number of prior authorized 
transports (for example, the initial ambulance company closes or no 
longer services that area), the initial request is cancelled. In this 
situation, a subsequent prior authorization request may be submitted 
for the same beneficiary and must include the required documentation in 
the submission. If multiple ambulance providers/suppliers are providing 
transports to the beneficiary during the same or overlapping time 
period, the prior authorization decision will only cover the provider/
supplier indicated in the provisionally affirmed prior authorization 
request. Any provider/supplier submitting claims for repetitive 
scheduled nonemergent ambulance transports for which no prior 
authorization request is recorded will be subject to 100 percent 
prepayment medical review of those claims.
    Additional information is available on the CMS Web site at http://go.cms.gov/PAAmbulance.

III. Collection of Information Requirements

    Section 1115A(d)(3) of the Act, as added by section 3021 of the 
Affordable Care Act, states that chapter 35 of title 44, United States 
Code (the Paperwork Reduction Act of 1995), shall not apply to the 
testing and evaluation of models or expansion of such models under this 
section. Consequently, this document need not be reviewed by the Office 
of Management and Budget under the authority of the Paperwork Reduction 
Act of 1995 (44 U.S.C. 35).

    Authority: Section 1115A of the Social Security Act.

    Dated: October 8, 2014.
Marilyn Tavenner,
Administrator, Centers for Medicare & Medicaid Services.
[FR Doc. 2014-26987 Filed 11-13-14; 8:45 am]
BILLING CODE 4120-01-P