Medicare Program; Extension of Prior Authorization for Repetitive Scheduled Non-Emergent Ambulance Transports

Seema Verma
Department of Health and Human Services
4 December 2018

[Federal Register Volume 83, Number 233 (Tuesday, December 4, 2018)]
[Notices]
[Pages 62577-62580]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2018-26334]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

[CMS-6063-N4]


Medicare Program; Extension of Prior Authorization for Repetitive 
Scheduled Non-Emergent Ambulance Transports

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

ACTION: Notice.

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SUMMARY: This notice announces a 1-year extension of the Medicare Prior 
Authorization Model for Repetitive Scheduled Non-Emergent Ambulance 
Transport. The extension of this model is applicable to the following 
states and the District of Columbia: Delaware, Maryland, New Jersey, 
North Carolina, Pennsylvania, South Carolina, Virginia, and West 
Virginia.

DATES: This extension begins on December 2, 2018 and ends on December 
1, 2019.

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

SUPPLEMENTARY INFORMATION:

I. Background

    Medicare may cover ambulance services, including air ambulance 
(fixed-wing and rotary-wing) services, if the ambulance service is 
furnished to a beneficiary whose medical condition is

[[Page 62578]]

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.
    Non-emergent transportation by ambulance is appropriate if either 
the-- (1) beneficiary is bed-confined and it is documented that the 
beneficiary's condition is such that other methods of transportation 
are contraindicated; or (2) 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 non-emergent 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 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.
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    \2\ Program Memorandum Intermediaries/Carriers, Transmittal AB-
03-106.
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    Medicare may cover repetitive, scheduled non-emergent 
transportation by ambulance if the--(1) medical necessity requirements 
described previously are met; and (2) 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 (Pub. 100-02), 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,'' \4\ the number of 
basic life support (BLS) non-emergent 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,'' \5\ indicated a 20 
percent nationwide improper payment rate for non-emergent ambulance 
transport. Likewise, in June 2013, the Medicare Payment Advisory 
Commission published a report \6\ that included an analysis of non-
emergent 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\ Government Accountability Office Cost and Medicare Margins 
Varied Widely; Transports of Beneficiaries Have Increased (October 
2012).
    \5\ Office of Inspector General Medicare Payment for Ambulance 
Transport (January 2006).
    \6\ Medicare Payment Advisory Commission, June 2013, pages 167-
193.
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    Section 1115A of the Social Security Act (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, as well as sections 1902(a)(1), 1902(a)(13), 1903(m)(2)(A)(iii), 
and 1934 (other than subsections (b)(1)(A) and (c)(5)) 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. Consistent with this standard, we will continue to waive the 
same provisions for the extension of this model as have been waived for 
the prior 4 years of the model. Additionally, 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.
    In the November 14, 2014 Federal Register (79 FR 68271), we 
published a notice entitled ``Medicare Program; Prior Authorization of 
Repetitive Scheduled Non-emergent Ambulance Transports,'' which 
announced the implementation of a 3-year Medicare Prior Authorization 
model that established a process for requesting prior authorization for 
repetitive, scheduled non-emergent ambulance transport rendered by 
ambulance providers/suppliers garaged in three 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 began on December 
1, 2014, and was originally scheduled to end in all three states on 
December 1, 2017.
    In the October 23, 2015 Federal Register (80 FR 64418), we 
published a notice titled ``Medicare Program; Expansion of Prior 
Authorization of Repetitive Scheduled Non-emergent Ambulance 
Transports,'' which announced the inclusion of six additional states 
(Delaware, the District of Columbia, Maryland, North Carolina, West 
Virginia, and Virginia) in the Repetitive Scheduled Non-Emergent 
Ambulance Transport Prior Authorization model in accordance with 
section 515(a) of the Medicare Access and CHIP Reauthorization Act of 
2015 (MACRA) (Pub. L. 114-10). These six states began participation on 
January 1, 2016, and the model was originally scheduled to end in all 
nine model states on December 1, 2017.
    In the December 12, 2017 Federal Register (82 FR 58400), we 
published a notice titled ``Medicare Program; Extension of Prior 
Authorization for Repetitive Scheduled Non-Emergent Ambulance 
Transports,'' which announced a 1-year extension of the prior 
authorization model in all states through December 1, 2018.

II. Provisions of the Notice

    This notice announces that the Medicare Prior Authorization Model 
for Repetitive Scheduled Non-Emergent Ambulance Transport is again 
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 an additional year while we 
continue to evaluate the model and determine if the model meets the 
statutory requirements for nationwide expansion under section 
1834(l)(16) of the the Act, as added by section 515(b) of MACRA (Pub. 
L. 114-10). The model is currently scheduled to end in all states on 
December 1, 2019. Prior authorization will not be available for 
repetitive scheduled non-emergent ambulance transportation services 
furnished after that date.
    We will continue to test whether prior authorization helps reduce 
expenditures, while maintaining or

[[Page 62579]]

improving quality of care, using the established prior authorization 
process for repetitive, scheduled non-emergent ambulance transport to 
reduce utilization of services that do not comply with Medicare policy.
    We will continue to use this prior authorization process to help 
ensure that all relevant clinical or medical documentation requirements 
are met before services are furnished to beneficiaries and before 
claims are submitted for payment. This prior authorization process 
further helps to ensure that payment complies with Medicare 
documentation, coverage, payment, and coding rules.
    The use of 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 coverage issues prior to furnishing services.
    The prior authorization process under this model 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.
    We have conducted and will continue to conduct outreach and 
education to ambulance providers/suppliers, as well as beneficiaries, 
through such methods as updating the operational guide, frequently 
asked questions (FAQs) on our website, a physician letter explaining 
the ambulance providers/suppliers' need for the proper documentation, 
and educational events and materials issued by the Medicare 
Administrative Contractors (MACs). We will also continue our recent 
initiative to help find alternative resources for beneficiaries who do 
not meet the requirements of the Medicare repetitive scheduled non-
emergent ambulance transport benefit. Additional information about the 
implementation of the prior authorization model is available on the CMS 
website at http://go.cms.gov/PAAmbulance.
    Under this model, submitting a prior authorization request is 
voluntary. However, an ambulance provider/supplier or beneficiary is 
encouraged to submit to the MAC a request for prior authorization along 
with all relevant documentation to support Medicare coverage of a 
repetitive, scheduled non-emergent ambulance transport. If prior 
authorization has not been requested by the fourth round trip in a 30-
day period, the subsequent claims will be stopped for prepayment 
review.
    In order for a prior authorization request to be provisionally 
affirmed, the request for prior authorization must meet all applicable 
rules and policies, including 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 non-
affirmative 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 resubmitted 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 non-
emergent 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 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 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 the beneficiary. When the subsequent 
claim is submitted to the MAC by the ambulance provider/supplier, it is 
linked to the prior authorization decision via the claims processing 
system, and the claim will be paid so long as all Medicare coding, 
billing, and coverage requirements are met. However, 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 because certain documentation, such as the trip 
record, needed in support of the claim cannot be submitted with a prior 
authorization request because it is not available until after the 
service is provided.
     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 non-
affirmative 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 additional documentation showing that 
Medicare requirements have been met. Alternatively, an ambulance 
provider/supplier could furnish the service and submit a claim with a 
non-affirmative prior authorization tracking number, at which point the 
MAC would deny the claim. The ambulance provider/supplier and 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 error(s) and resubmit the

[[Page 62580]]

prior authorization request with appropriate documentation.
     Scenario 4: If an ambulance provider or supplier renders a 
service to a beneficiary and does not request prior authorization by 
the fourth round trip in a 30-day period, and the claim is submitted to 
the MAC for payment, then the claim will be stopped for prepayment 
review and documentation will be requested.
    ++ If the claim is determined to be for services that were not 
medically necessary or for which there was insufficient documentation, 
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.
    Only one prior authorization request per beneficiary per designated 
time period can be provisionally affirmed. If the initial ambulance 
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 ambulance 
provider/supplier indicated in the provisionally affirmed prior 
authorization request. Any ambulance provider/supplier submitting 
claims for repetitive, scheduled non-emergent ambulance transports for 
which no prior authorization request is submitted by the fourth round 
trip in a 30-day period will be subject to 100 percent prepayment 
medical review of those claims.
    Under the model, we will work to limit any adverse impact on 
beneficiaries and to educate beneficiaries about the process. If a 
prior authorization request is non-affirmed, and the claim is still 
submitted by the ambulance provider/supplier, the claim will be denied, 
but beneficiaries will continue to have all applicable administrative 
appeal rights. We have also recently implemented a process to help find 
alternative resources for beneficiaries who do not meet the 
requirements of the Medicare repetitive scheduled non-emergent 
ambulance transport benefit.
    Additional information is available on the CMS website at http://go.cms.gov/PAAmbulance.

III. Collection of Information Requirements

    Section 1115A(d)(3) of the 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.

IV. Regulatory Impact Statement

    This document announces a 1-year extension of the Medicare Prior 
Authorization Model for Repetitive Scheduled Non-Emergent Ambulance 
Transport. Therefore, there are no regulatory impact implications 
associated with this notice.

    Authority: Section 1115A of the Act.

    Dated: November 27, 2018.
Seema Verma,
Administrator, Centers for Medicare & Medicaid Services.
[FR Doc. 2018-26334 Filed 11-30-18; 11:15 am]
BILLING CODE 4120-01-P