Non-Affirmed Code Crosswalk: Prior Authorization Request

Published 08/16/2022

Palmetto GBA decision letters for non-affirmed Repetitive, Scheduled, Non-emergent Ambulance Transport (RSNAT) prior authorization (PA) requests  contain a non-affirmation reason code. Formerly PA non-affirmation letters contained a PA reason (PAR) code. Non-affirmation letters will now contain the standardized Ambulance Transport Reason Codes, which were developed by CMS. 

Note: You will no longer see PAR codes on non-affirmation letters. The PAR codes are shown on this chart with their corresponding AMB non-affirmation reason codes. The AMB codes will be the ones appearing on provider non-affirmation letters.

Refer to Title 42 of the Code of Federal Regulations (CFR) § 410.40 for Medicare’s coverage requirements for ambulance transports.

Code

Description

PAR 1

AMB1F

The documentation received did not contain the necessary PCS (Physician Certification Statement). 

PAR 2

AMB6Z

The documentation received did not indicate the origin and/or destination of the transports.

PAR 3

AMB4D

AMB4E

The PCS received is missing a physician signature with credentials or is illegible/incomplete/invalid.  

PAR 4

AMB4H

The PCS received is not dated, or the date is pre-filled. 

PAR 5

AMB4E

The referring physician name on the Prior Authorization request form must match the certifying physician on the PCS.  

PAR 6

AMB4H

The PCS received does not indicate why transportation by any other means is contraindicated. 

PAR 7

AMB4F

The physician’s signature on the PCS was obtained after the date requested as the "Start of the 60-Day Period" on the Prior Authorization request form.  This signature must be obtained prior to the transport for scheduled, repetitive transports. 

PAR 8

AMB4F

The physician’s signature on the PCS is greater than 60 days prior to the start of the 60-day period provided on the Prior Authorization request form. The PCS is only valid for a period of 60 days. 

PAR 9

AM00Z

The "Request Type" section on the Prior Authorization request form was incomplete.

  • Initial
  • Resubmission
  • Expedited. If this type is indicated, you must provide the reason the request should be expedited.
  • Number of transports requested

PAR 10

AM00Z

The "Ambulance Supplier/Provider Information" section on the Prior Authorization request form was incomplete.

  • Provider name
  • NPI
  • PTAN
  • Address
  • State where the ambulance is garaged

PAR 11

AM00Z

The "Beneficiary Information" section on the Prior Authorization request form was incomplete.

  • First name
  • Last name
  • Health insurance number
  • Date of birth

PAR 13

AM00Z

The "Requestor Information" section on the Prior Authorization request form was incomplete.

  • Name
  • Phone number
  • Signature
  • Date

PAR 14 

AM600

The documentation submitted does not indicate that transportation by another means is contraindicated.  The documentation supports that alternative services should have been used whether or not they were available.

PAR 14A

AM601

No supporting medical documentation (e.g., history and physical, wound care notes, progress notes, etc.) was received with this submission. 

PAR 14B

AM600

The documentation submitted does not provide an indication of patient status and needs at the time of the transport period.

PAR 14C 

AM601

The supporting documentation is not legible.

PAR 14D

AM600 

The documentation does not indicate bed-confined status or inability to transfer by other means.

PAR 14E 

AMB1Y

The documentation submitted is not for the patient indicated on the PA form and PCS.

PAR 15

AMB2L

The documentation received does not support expedited requests.

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