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Serving the Central New Jersey area
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"BECAUSE YOU HAVE A CHOICE"
Facility FormsAmbulance Prior Authorization Documentation Requirement
Medicare Coverage of Ambulance Services Booklet
Medicare & You - 2015
Ambulance Transportation is in Crisis! Medicare has implemented a new procedure where by prior authorizations are needed for repetitive non-emergency ambulance transportation. ABBA Medical Transportation, a family owned business, has been severely impacted by this pilot program and as such has turn away Medicare patients in need. Patients who are truly bedbound and ill cannot get to their appointments.
Medicare is attempting to save money on the backs of those in need. Seniors who have worked for many years and are entitled to benefits are getting short changed. Those who need it the most are being left behind. 47 other States remain unaffected. I urge anyone seeing this message to call ABBA and we will provide you with the necessary information, to contact Medicare and Norvitas to voice your concerns. PLEASE contact Medicare, your congressman, senator and AARP and let your voice be heard! Together, we can make a difference for those who need it most.
Posted on Facebook by ABBA Medical Transportation on Tuesday, May 12, 2015
New Medicare Rule effective 12/1/14
CMS Issues Notice About Prior Authorization Model in PA, NJ and SC
Requests Can Start on December 1, 2014
On November 13, 2014, CMS issued a Notice in the Federal Register officially announcing a 3-year Medicare Prior Authorization model for repetitive scheduled non-emergent ambulance transports in the states of New Jersey, Pennsylvania, and South Carolina. The new model means that certain ambulance services in these three states must soon obtain prior authorization for repetitive, scheduled non-emergent transports by submitting a host of documentation to their Medicare Administrative Contractors (MACs).
Affected ambulance suppliers can start submitting prior authorization requests on December 1, 2014 to either Novitas or Palmetto, and agencies should be preparing now for this new model. This model is effective for Medicare-covered repetitive, scheduled non-emergent transports occurring on or after December 15, 2014.
Why CMS Is Doing This
CMS says it's trying to crack down on "high incidences of improper payments" for non-emergency transports. The agency points to the rapidly increasing number of Basic Life Support (BLS) non-emergent transports over the past few years, citing findings from several reports including:
Types of Transports to Which the Model Applies
The prior authorization model applies to repetitive, scheduled non-emergent ambulance transports, and it will affect the following ambulance HCPCS codes:
What Ambulance Services Are Affected?
This model affects ambulance suppliers garaged in 3 states - New Jersey, Pennsylvania, and South Carolina. Although the Notice states throughout that it applies to ambulance "providers/suppliers," CMS stated in several Special Open Door Forums, and in its reference materials about the model, that the model affects suppliers only (not institutionally based ambulance providers).
How Long Will the Model Last?
Right now, the model is slated to be in effect for 3 years. However, it could be extended in the future, and to other states.
When a Supplier Should Obtain Prior Authorization Under the Model
Suppliers should 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, before the fourth round trip in a 30-day period. CMS is taking the position that, for this model, 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." We recommend that ambulance services submit a prior authorization request as soon as they know a patient is going to require scheduled, repetitive non-emergent ambulance services on an ongoing basis.
Review Time Periods
After receipt of all documentation, CMS says the MACs will make every effort to conduct a review and postmark the notification of their decision on a prior authorization request as follows: • Initial Requests - 10 business days • Subsequent Requests (after a nonaffirmative decision on an initial prior authorization request) - 20 business days • Expedited Review - 2 business days
How Many Trips Can be Approved?
A MAC may approve up to 40 round trips (which equates to 80 one-way trips) per prior authorization request in a 60-day period. Or a MAC 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 in less than a 60-day period. Transports exceeding 40 round trips (or 80 one-way trips) in a 60-day period will require an additional prior authorization request.
The Scenarios Under the Model
CMS outlines several scenarios under the prior authorization model in its Notice:
CMS Says Only One Prior Authorization Per Beneficiary at a Time
In the Notice, CMS states that "only one prior authorization request per beneficiary per designated time period can be provisionally affirmed." CMS also states that "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." Ambulance services should be aware that they may need to have a previous prior authorization canceled and submit a new request if they take over providing non-emergent repetitive transportation to a patient.