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Printed Date: 9/22/2015
What We Did
In 2016, Palmetto GBA conducted several Organizational Process Improvement Coaching Projects (OPICPs) throughout the state of South Carolina with ambulance providers of repetitive scheduled non-emergent ambulance transports subject to prior authorization (PA).
OPICP is a process engineering collaboration between:
The basis of OPICP is the Health Information Supply Chain, which begins with the encounter between the beneficiary and the provider, moves to the coding and billing of the claim, and ends with the processing of the claim by Palmetto GBA and the use of claim information by CMS. Errors may occur at each step and for a variety of reasons, which is why Palmetto GBA initiated this extensive work. The intent was to help CMS, you, the providers, and most importantly, our Medicare beneficiaries who qualify for coverage of these services.
What We Learned
A lot! Part of implementing this model was identifying new issues that needed to be addressed. For example, when prior authorization was first rolled out in a state, errors such as no start date included on the PA request form were seen. The issues that are in this article are more advanced than the initial ones covered in previous education.
Claims Processing Scenarios Under the Repetitive Scheduled Non-Emergent Ambulance Prior Authorization Model
Claims Processing Steps to Trigger an ADR: CMS and Palmetto GBA encourage ambulance providers to participate in the PA model, which is not mandatory at this time.
For providers who do not want to participate and instead want to receive an Additional Documentation Request (ADR), the only way to bypass PA and get the ADR is to never submit a PA request for that patient. Simply submit the claims as normal and on the fourth round trip an ADR will be sent.
Claims Processing Steps to Trigger Appeal Rights: If the provider does submit a PA, receives a non-affirmation and wants to submit a claim for processing in order to receive a denial with appeal rights, they will need to submit it with the non-affirmed UTN on the claim. The claim will deny, allowing the provider to follow the normal appeal process. Otherwise, claims submitted without UTNs will hit a front end edit for not having a UTN on the claim.
Claims Processing Steps for Non-Repetitive Ambulance Transports: If an ambulance provider submits a claim for a beneficiary who has an affirmed or non-affirmed PA request on file, but for a non-repetitive ambulance transport, they must append the UTN to this non-repetitive claim in order for it to avoid the front end edit which requires the UTN. Denials will receive appeal rights.
The PA program applies to all non-emergent (A0426, A0428) ambulance transports, regardless of the origin or destination (SE1514 (PDF, 138 KB).
Legal Representative (Rep) Payees
Initially the ambulance PA program did not apply to beneficiaries with a Legal Representative Payee on file for transports provided prior to April 1, 2016.
However, the exclusion of claims for beneficiaries with a representative payee from the repetitive scheduled non-emergent ambulance transport PA program was discontinued. Beneficiaries with a representative payee are now included in PA for claims with dates of service on or after April 1, 2016. Letters were sent to beneficiaries impacted by this change.
If a decision letter was received in response to a PA request for a date of service prior to April 1, 2016, and the letter indicated the beneficiary had a rep payee on file, those claims were to be submitted without the UTN indicated on the letter. If the UTN was submitted for those dates of service, the claim(s) may have been denied or rejected or you may have received a development letter.
Claims for those beneficiaries that spanned the April 1, 2016 date were pro-rated to accommodate the dates before and after the inclusion of legal rep payee beneficiaries.
Signature Requirements and Credentials Under the Repetitive Scheduled Non-emergent Ambulance Prior Authorization Model
Why would credentials be required if the NPI and PTAN are provided with the PA request? Remember, the PCS requirement that a physician order the repetitive scheduled non-emergent ambulance transports. See SE1514 article on Overview of the Repetitive Scheduled Non-emergent Ambulance Prior Authorization Model. The credentials indicate whether or not the required professional ordered the service.
Note: 'Dr.' is a title and not a credential. The Educational Links section of this article contains more information on signature requirements.
Suggested Best Practices
As part of this ongoing process we developed the following tools:
Where We Are Now
We have moved forward with solutions to barriers and making the process more user-friendly for ambulance providers. It’s all about ensuring that beneficiaries who qualify receive the services they are afforded under Medicare.
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Last Updated: 06/08/2017