Letter for Patients with a Legal Representative for Repetitive Scheduled Non-Emergent Ambulance Transport Prior Authorization

In the near future Medicare patients will be receiving this letter if they have a Legal Representative and are receiving repetitive scheduled non-emergent ambulance transports for the prior authorization project.

An Important Message from Medicare:
Medicare began a prior authorization program for repetitive scheduled non-emergent ambulance transportation services in South Carolina in December, 2014 and in North Carolina, Virginia, and West Virginia in January, 2016. When the program began, Medicare beneficiaries who had legal representative payees on file through Social Security Administration (SSA) were excluded from the prior authorization process. Starting April 01, 2016, the program will include beneficiaries with a legal representative payee on file. 

You are receiving this notification because according to our records, you have a legal representative payee on file and have received repetitive ambulance services in the past.
Repetitive ambulance services means you get 3 or more round trips in a 10-day period or at least one round trip per week for 3 weeks or more. Prior authorization means Medicare will review medical documents to make sure you meet Medicare’s coverage requirements for the repetitive transportation services you need.

If you continue to receive these services on or after April 1, 2016, Medicare will use a prior authorization process to make sure you meet Medicare’s coverage requirements for repetitive, scheduled non-emergency ambulance transportation services.

What do I need to do?
You or your ambulance company may submit a prior authorization request under this program. The Medicare contractor will review the prior authorization request to determine if you meet Medicare’s coverage requirements for the ambulance transportation. You will receive a letter generally within 10-20 business days informing you if your request was approved.

What if my request is not approved?
If your request is not approved and you have additional information that supports your need for repetitive, scheduled non-emergency ambulance transportation, either you or your ambulance company may submit another prior authorization request with the necessary documents to the Medicare contractor for consideration.

What if my request is not approved and I continue receiving ambulance transport?
Medicare does not cover non-emergency ambulance transport services that do not meet all coverage requirements, including medical necessity. If your request is not approved and you continue receiving these services, the ambulance company may submit the claim to Medicare and bill you for all denied charges even if you did not sign an Advance Beneficiary Notice of Noncoverage (ABN). You or your ambulance company may also appeal the denied claim.

Are my benefits changing?
No. Your Medicare ambulance benefit is not changing. Medicare will continue to cover non-emergency ambulance transportation if, in addition to meeting other coverage requirements, one of the following medical necessity requirements applies to you:

  • You are confined to a bed, and it is documented that due to your medical condition, other methods of transportation would endanger your health; OR
  • Ambulance transportation is medically required due to your medical condition, regardless of bed confinement.

Who can I contact if I need help?
There are state and local services that may help you with your transportation needs. If you need assistance finding other transportation services, please contact Eldercare at 1-800-677-1116 or your local State Health Insurance Assistance Program (SHIP). To get the phone number for the SHIP in your state, visit shiptacenter.org or call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

If you have Medicaid or Programs of All-Inclusive Care for the Elderly (PACE), you may contact those programs to see if you qualify for help with transportation coverage.

For information about Social Security’s Representative Payee Program, please go to www.ssa.gov/payee/.

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