Ambulance Prior Authorization

Prior Authorization 
Prior authorization is a process in which a request is made to Medicare to approve a service before a claim is submitted for payment. Prior authorization helps ensure that all Medicare rules and regulations are met before services are given to the patient.

Prior authorization is not required for ambulance services. Requesting prior authorization is voluntary as part of a model for a very specific type of ambulance service: repetitive, scheduled, non-emergent ambulance transports.

Repetitive ambulance services are ambulance transports that occur:

• Three or more times during a 10-day period: or 
• At least once per week for at least three weeks

Repetitive, scheduled, non-emergent ambulance transports are most often needed for a limited time by people who are receiving dialysis or cancer treatment. 
 
Prior Authorization of Repetitive, Scheduled, Non-Emergent Ambulance Transports (RSNAT) 
Medicare began a prior authorization model for repetitive, scheduled, non-emergent ambulance transports in limited states in 2014. The model is expanding nationwide in 2022. This model will apply to people with Railroad Medicare nationwide for transports on and after August 1, 2022.

This model does not change the Medicare ambulance benefit and only impacts repetitive, scheduled, non-emergent transports.

Medicare Coverage of RSNAT
Medicare can cover non-emergency ambulance transportation if either:

• You are bed-confined and there is documentation that it would be unsafe for you to travel by another method; or 
• You are not bed-confined but your medical condition makes ambulance transport medically necessary for you

Medicare may cover scheduled, repetitive, non-emergency ambulance transports if, before you are transported, the ambulance supplier receives a written order from your physician that certifies the transports are medically necessary. 

How the Prior Authorization of RSNAT Will Work 
Prior authorization is not needed for the first three round trips in a 30-day period. Before your fourth trip, your ambulance company may submit a prior authorization request to Railroad Medicare. Prior authorization cannot be requested prior to July 18, 2022, for transports on and after August 1, 2022. 

Prior authorization can be requested for up to 40 non-emergency scheduled round-trip ambulance services (which equals 80 trips) in a 60-day period. For scheduled trips beyond the prior authorized number, a second prior authorization request is required. When submitting the request, your ambulance company will indicate the start date of the prior authorization period and the number of transports requested. 

When Railroad Medicare receives a prior authorization request, we will review the documentation to determine if it meets Medicare coverage requirements. Requests will either be affirmed (approved) or non-affirmed (denied). Railroad Medicare will make every effort to make a decision within 10 business days of when we receive each request.

Notification of a Prior Authorization Decision
We will send you a letter to let you know if the transportation request was approved. 

You will receive an affirmed decision letter if Railroad Medicare approves the prior authorization request for ambulance services. Your ambulance provider will then submit claims for processing. An affirmation is not a guarantee of payment. 

You will receive a non-affirmed decision letter if Railroad Medicare denies the prior authorization request for ambulance services. A non-affirmation decision may be based on medical necessity, or the request may not have had all the necessary information. If a request is denied, either you or the ambulance company can submit another request with additional information/documentation to support why you and they feel the transports are medically necessary. There is no limit on the number of times a request can be submitted. 

Transports After a Non-Affirmed Decision 
Non-emergency transport services that are not medically necessary are not a Medicare-covered benefit. If prior authorization is denied, and you continue to have the non-emergency ambulance transports, the claims will be denied and the ambulance company may bill you for the full amount of the charges. You or the ambulance company can appeal the denials. Include any documentation/notes to support why you feel the transports were medically necessary. Appeals are new and independent reviews conducted by another department that does not take part in the prior authorization process.

Prior Authorization Is Voluntary
If an ambulance supplier chooses to submit a claim for RSNAT services without requesting prior authorization, the claim will be subject to prepayment review. This means Medicare will request medical records/documentation from the supplier and review the claim before processing it. 

If you have questions about the prior authorization process or a specific ambulance service, you can call our Beneficiary Contact Center toll-free at 800–833–4455, Monday through Friday, from 8:30 a.m. to 7 p.m. ET. For the hearing impaired, call TTY/TDD at 877–566–3572.