Medicare Sets New Standards for Ambulance Transports
Medicare Program; Expansion of Prior Authorization for Repetitive Scheduled Non-Emergent Ambulance Transports
A Notice by the
Publication Date:
Agencies:
Dates: This expansion will begin on
Entry Type: Notice
Action: Notice.
Document Citation: 80 FR 64418
Page: 64418 -64421 (4 pages)
Agency/Docket Number: CMS-6063-N2
Document Number: 2015-27030
Shorter URL: https://federalregister.gov/a/2015-27030
Action
Notice.
Summary
This notice announces an expansion of the 3-year Medicare Prior Authorization Model for
DATES:
This expansion will begin on
FOR FURTHER INFORMATION CONTACT:
Questions regarding the Medicare Prior Authorization Model Expansion for
SUPPLEMENTARY INFORMATION:
I. Background
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]
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.
In addition to the medical necessity requirements, the service must meet all other
According to a study published by the
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
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 physicians' 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
In the
Section 515(a) of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) (Pub. L. 114-10), requires expansion of the previously referenced prior authorization model to cover, effective not later than
We will continue to test whether prior authorization helps reduce expenditures, while maintaining or 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
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
The use of prior authorization does not create new clinical documentation requirements. Instead, it requires the same information that is already required to support
The prior authorization process under this model will apply in the additional six states listed previously for the following codes for
A0426 Ambulance service, advanced life support, non-emergency transport, Level 1 (ALS1).
A0428 Ambulance service, BLS, non-emergency transport.
While prior authorization in the additional six states 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.
Prior to the start of the expansion, we will conduct (and thereafter will continue to conduct) outreach and education to ambulance providers/suppliers, as well as beneficiaries, through such methods as the issuance of an operational guide, frequently asked questions (FAQs) on our Web site, a beneficiary mailing, a physician letter explaining the ambulance providers/suppliers' need for the proper documentation, and educational events and materials issued by the 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 is encouraged to submit to the MAC a request for prior authorization along with all relevant documentation to support
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
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
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 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
Scenario 2: When an ambulance provider/supplier or beneficiary submits a prior authorization request, but all relevant
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 not to be 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 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 non-emergent ambulance transports for which no prior authorization request is recorded will be subject to 100 percent pre-payment 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
IV. Regulatory Impact Statement
This document announces an expansion of the 3-year Medicare Prior Authorization Model for
Authority:
Section 1115A of the Social Security Act.
Dated:
Acting Administrator,
[FR Doc. 2015-27030 Filed 10-22-15;
BILLING CODE P
Footnotes
1. 42 CFR 410.40(d)(1).
2. Program Memorandum Intermediaries/Carriers,
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.
4. Government Accountability Office Cost and Medicare Margins Varied Widely; Transports of Beneficiaries Have Increased (October 2012).
5.
6.
[*Federal RegisterBF 2015-10-23]
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