Beneficiary Non-Affirmation Letter for Ambulance Prior Authorization

An Important Message from Medicare
Medicare expanded the prior authorization demonstration program for repetitive, scheduled non-emergency ambulance transportation to include Virginia, West Virginia, North Carolina and South Carolina. This type of transport occurs when the service is provided three or more times in 10 days or once per week for three consecutive weeks.

If you receive this type of ambulance service in those states, you or your ambulance company may use a prior approval process called "prior authorization." Under prior authorization, Medicare will review your medical documents to make sure you meet Medicare’s coverage requirements for the transportation service at the time of transport. This review must occur near the beginning of your transports. Either you or your ambulance company may submit a prior authorization request to the appropriate Medicare contractor.

You are receiving this letter because Medicare reviewed a prior authorization request and has determined that you do not qualify for coverage of repetitive, scheduled non-emergency ambulance transport services.

The Medicare ambulance benefit has not changed. Non-emergency transportation by ambulance is covered if either:

A. You are confined to a bed, and other transport methods would endanger your health; or
B. The transport requires trained staff to be present due to your medical condition.

If 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 appropriate Medicare Contractor. Contact your ambulance company to learn if they are submitting another prior authorization request.

Even if you have been getting Medicare covered transport services for some time, it may be possible that Medicare will not cover those services because you could use another type of transportation. Non-emergency ambulance transport services that are not medically necessary are not a Medicare covered benefit. If you choose to continue receiving non-emergency ambulance transport services, the ambulance company may bill you for all 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.

There are state and local services that may help you with your transportation needs. If you need assistance locating other transportation services, please contact Eldercare at 1-800-677-1116, or your local State Health Insurance Assistance Program:

• For the State of South Carolina:
  • State Health Insurance Assistance Program (SHIP) website
  • Phone: 800-868-9095
• For the State of North Carolina:
  • North Carolina SHIP website
  • Phone: 855-408-1212
• For the State of Virginia
  • Virginia Insurance Counseling and Assistance Program – VICAP website
  • Phone: 800-552-3402
• For the State of West Virginia:
  • State Health Insurance Assistance Programs (SHIP) Website
  • Phone: 877-987-4463 or (304) 558-3317 

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

If you have additional questions, visit Medicare.gov or call 1-800-MEDICARE (1-800-633-4227). TTY users should call 877-486-2048.

Sincerely,

Provider Outreach and Education
Palmetto GBA