Extended Affirmation Period for Beneficiaries with Chronic Conditions Participating in the Repetitive, Scheduled Non-Emergent Ambulance Prior Authorization Model

Since implementation, the Medicare Prior Authorization Model for Repetitive, Scheduled Non-Emergent Ambulance Transport has instructed the Medicare Administrative Contractors (MACs) to allow up to 80 one-way trips in a 60-day period per prior authorization request. Situations requiring more than 80 one-way trips in a 60-day period require a separate prior authorization request.

Palmetto GBA conducted several Organizational Process Improvement Coaching Projects (OPICPs) throughout the state of South Carolina with ambulance suppliers of these transports and continues to work with the Centers for Medicare & Medicaid Services (CMS) on reducing provider burden for patients with chronic conditions.

Effective June 3, 2019, MACs may allow up to 240 one-way trips in a 180 day period per prior authorization request for beneficiaries with chronic conditions that are deemed not likely to change over time that also meet all Medicare requirements for repetitive non-emergent ambulance transport. The medical records must clearly indicate the condition is chronic. In addition, two previous prior authorizations requests must have established that the beneficiary’s medical condition has not changed or has deteriorated.

Additionally:

• The decision to allow an extended affirmation period is at MAC discretion. Ambulance suppliers cannot request transports beyond the current maximum of 80 transports per 60-day period;
• Ambulance suppliers are responsible for maintaining a valid Physician Certification Statement (PCS) at all times;
• The MACs reserve the right to request the PCS at any time; and
• Each individual time a patient is transported by ambulance, that transport must be reasonable and necessary regardless of whether a new prior authorization is required

The MACs shall continue to allow up to 80 one-way trips in a 60-day period per prior authorization request for beneficiaries with acute conditions meeting all Medicare requirements for repetitive non-emergent ambulance transport.