Medicare Program; Prior Authorization of Repetitive Scheduled Nonemergent Ambulance Transports, 68271-68273 [2014-26987]

Download as PDF Federal Register / Vol. 79, No. 220 / Friday, November 14, 2014 / Notices DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services [CMS–6063–N] Medicare Program; Prior Authorization of Repetitive Scheduled Nonemergent Ambulance Transports Centers for Medicare & Medicaid Services (CMS), HHS. ACTION: Notice. AGENCY: This notice announces a 3year Medicare Prior Authorization model for repetitive scheduled nonemergent ambulance transport in the states of New Jersey, Pennsylvania, and South Carolina where there have been high incidences of improper payments for these services. DATES: This model will begin on December 1, 2014 in South Carolina, New Jersey, and Pennsylvania. FOR FURTHER INFORMATION CONTACT: Angela Gaston, (410) 786–7409. Questions regarding the Medicare Prior Authorization Model for Repetitive Scheduled Nonemergent Ambulance Transport should be sent to AmbulancePA@cms.hhs.gov. SUPPLEMENTARY INFORMATION: SUMMARY: mstockstill on DSK4VPTVN1PROD with NOTICES I. Background Medicare covers ambulance services, including air ambulance (fixed wing and rotary wing) services, when furnished to a beneficiary whose medical condition is such that other means of transportation are contraindicated. The beneficiary’s condition must require both the ambulance transportation itself and the level of service provided in order for the billed service to be considered medically necessary. Nonemergent transportation by ambulance is appropriate if either—(1) the beneficiary is bed-confined and it is documented that the beneficiary’s condition is such that other methods of transportation are contraindicated; or (2) the beneficiary’s medical condition, regardless of bed confinement, is such that transportation by ambulance is medically required. Thus, bed confinement is not the sole criterion in determining the medical necessity of nonemergent ambulance transportation; rather, it is one factor that is considered in medical necessity determinations.1 A repetitive ambulance service is defined as medically necessary ambulance transportation that is 1 42 CFR 410.40(d)(1). VerDate Sep<11>2014 17:37 Nov 13, 2014 Jkt 235001 furnished in 3 round trips or more times during a 10-day period, or at least once per week for at least 3 weeks.2 Repetitive ambulance services are often needed by beneficiaries receiving dialysis, wound care, or cancer treatment. Medicare may cover repetitive, scheduled, nonemergent transportation by ambulance if—(1) the medical necessity requirements described previously are met; and (2) the ambulance provider/supplier, before furnishing the service to the beneficiary, obtains a written order from the beneficiary’s attending physician certifying that the medical necessity requirements are met (see 42 CFR 410.40(d)(1) and (2)).3 In addition to the medical necessity requirements, the service must meet all other Medicare coverage and payment requirements, including requirements relating to the origin and destination of the transportation, vehicle and staff, and billing and reporting. Additional information about Medicare coverage of ambulance services can be found in 42 CFR 410.40, 410.41, and in the Medicare Benefit Policy Manual, Chapter 10, at https://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/ downloads/bp102c10.pdf. According to a study published by the Government Accountability Office in October 2012, entitled ‘‘Costs and Medicare Margins Varied Widely; Transports of Beneficiaries Have Increased’’, the number of Basic Life Support (BLS) nonemergent transports for Medicare fee-for-service beneficiaries increased by 59 percent from 2004 to 2010. A similar finding published by the Department of Health and Human Services Office of Inspector General in a 2006 study, entitled ‘‘Medicare Payments for Ambulance Transports’’, indicated a 20 percent nationwide improper payment rate for nonemergent ambulance transport. Likewise, in June 2013, the Medicare Payment Advisory Commission published a report 4 that included an analysis of nonemergent ambulance transports to dialysis facilities and found that, during the 5-year period between 2007 and 2011, the volume of transports to and from a dialysis facility increased 20 percent, more than twice the rate of all other ambulance transports combined. 2 Program Memorandum Intermediaries/Carriers, Transmittal AB–03–106. 3 Per 42 CFR 410.40(d)(2), the physician’s order must be dated no earlier than 60 days before the date the service is furnished. 4 Medicare Payment Advisory Commission, June 2013, pages 167–193. PO 00000 Frm 00063 Fmt 4703 Sfmt 4703 68271 Section 1115A of the Act authorizes the Secretary to test innovative payment and service delivery models to reduce program expenditures, while preserving or enhancing the quality of care furnished to Medicare, Medicaid and Children’s Health Insurance Program beneficiaries. Section 1115A(d)(1) of the Act authorizes the Secretary to waive such requirements of Titles XI and XVIII and of sections 1902(a)(1), 1902(a)(13), and 1903(m)(2)(A)(iii) of the Act as may be necessary solely for purposes of carrying out section 1115A of the Act with respect to testing models described in section 1115A(b) of the Act. For these models, consistent with this standard, we will waive such provisions of sections 1834(a)(15) and 1869(h) of the Act that limit our ability to conduct prior authorization. While these provisions are specific to durable medical equipment and physician services, we will waive any portion of these sections as well as any portion of 42 CFR 410.20(d), which implements section 1869(h) of the Act, that could be construed to limit our ability to conduct prior authorization. We have determined that the implementation of this model does not require the waiver of any fraud and abuse law, including sections 1128A, 1128B, and 1877 of the Act. Thus, providers and suppliers affected by this model must comply with all applicable fraud and abuse laws. II. Provisions of the Notice We plan to implement a 3-year Medicare Prior Authorization process for repetitive scheduled nonemergent ambulance transport rendered by ambulance providers/suppliers garaged in 3 states (New Jersey, Pennsylvania, and South Carolina). These states were selected as the initial states for the model because of their high utilization and improper payment rates for these services. The model will begin in on December 1, 2014, in South Carolina, New Jersey, and Pennsylvania. We plan to test whether prior authorization helps reduce expenditures, while maintaining or improving quality of care, using a model that would establish a prior authorization process for repetitive scheduled nonemergent ambulance transport to reduce utilization of services that do not comply with Medicare policy. We plan to use this prior authorization process to ensure that all relevant clinical or medical documentation requirements are met before services are rendered to beneficiaries and before claims are E:\FR\FM\14NON1.SGM 14NON1 mstockstill on DSK4VPTVN1PROD with NOTICES 68272 Federal Register / Vol. 79, No. 220 / Friday, November 14, 2014 / Notices submitted for payment. This prior authorization process will further ensure that payment complies with Medicare documentation, coverage, payment, and coding rules. The use of prior authorization will not create new clinical documentation requirements. Instead, it will require the same information that is already required to support Medicare payment, just earlier in the process. Prior authorization allows providers and suppliers to address issues with claims prior to rendering services. The prior authorization process under this model will be available for the following codes for Medicare payment: • A0425 Ambulance service, basic life support (BLS)/advanced life support (ALS) ground mileage (per statute mile). • A0426 Ambulance service, advanced life support, nonemergency transport, Level 1 (ALS1). • A0428 Ambulance service, basic life support (BLS), nonemergency transport. Prior to the start of the model, we will conduct (and thereafter will continue to conduct) outreach and education to ambulance providers/suppliers, as well as beneficiaries, through such methods as open door forums, frequently asked questions (FAQs) on our Web site, other Web site postings, and educational materials issued by the Medicare Administrative Contractors (MACs). Additional information about the implementation of the prior authorization model is available on the CMS Web site at https://go.cms.gov/ PAAmbulance. Under this model, an ambulance provider/supplier or beneficiary will be encouraged to submit to the MAC a request for prior authorization along with all relevant documentation to support Medicare coverage of a repetitive scheduled nonemergent ambulance transport. Submitting a prior authorization request will be voluntary. (However, if prior authorization has not been requested before the fourth round trip in a 30-day period, the claims will be stopped for pre-payment review). In order to be provisionally affirmed, the request for prior authorization must meet all applicable rules and policies, and any local coverage determination (LCD) requirements for ambulance transport claims. A provisional affirmation is a preliminary finding that a future claim submitted to Medicare for the service likely meets Medicare’s coverage, coding, and payment requirements. After receipt of all relevant documentation, the MACs will make every effort to conduct a review and postmark the notification of their decision on a prior authorization VerDate Sep<11>2014 17:37 Nov 13, 2014 Jkt 235001 request within 10 business days for an initial submission. Notification will be provided to the ambulance provider/ supplier and to the beneficiary. If a subsequent prior authorization request is submitted after a nonaffirmative decision on an initial prior authorization request, the MACs will make every effort to conduct a review and postmark the notification of their decision on the request within 20 business days. An ambulance provider/supplier or beneficiary may request an expedited review when the standard timeframe for making a prior authorization decision could jeopardize the life or health of the beneficiary. If the MAC agrees that the standard review timeframe would put the beneficiary at risk, the MAC will make reasonable efforts to communicate a decision within 2 business days of receipt of all applicable Medicarerequired documentation. As this model is for nonemergent services only, we expect requests for expedited reviews to be extremely rare. A provisional affirmative prior authorization decision may affirm a specified number of trips within a specific amount of time. The prior authorization decision, justified by the beneficiary’s condition, may affirm up to 40 round trips (which equates to 80 one-way trips) per prior authorization request in a 60-day period. Alternatively, a provisional affirmative prior authorization decision may affirm less than 40 round trips in a 60-day period, or may affirm a request that seeks to provide a specified number of transports (40 round trips or less) in less than a 60-day period. A provisional affirmative decision can be for all or part of the requested number of trips. Transports exceeding 40 round trips (or 80 one-way trips) in a 60-day period will require an additional prior authorization request. The following describes examples of various prior authorization scenarios: • Scenario 1: When an ambulance provider/supplier or beneficiary submits a prior authorization request to the MAC with appropriate documentation and all relevant Medicare coverage and documentation requirements are met for the ambulance transport, the MAC will send a provisional affirmative prior authorization decision to the ambulance provider/supplier and to the beneficiary. When the claim is submitted to the MAC by the ambulance provider/supplier, it is linked to the prior authorization via the claims processing system and the claim will be paid so long as all Medicare coding, billing, and coverage requirements are met. However, after submission, the PO 00000 Frm 00064 Fmt 4703 Sfmt 4703 claim could be denied for technical reasons, such as the claim was a duplicate claim or the claim was for a deceased beneficiary. In addition, a claim denial could occur since certain documentation, such as the trip record, needed in support of the claim cannot be reviewed on a prior authorization request. • Scenario 2: When an ambulance provider/supplier or beneficiary submits a prior authorization request, but all relevant Medicare coverage requirements are not met, the MAC will send a nonaffirmative prior authorization decision to the ambulance provider/supplier and to the beneficiary, advising them that Medicare will not pay for the service. The provider/supplier or beneficiary may then resubmit the request with documentation showing that Medicare requirements have been met. Alternatively, an ambulance provider/ supplier could render the service, and submit a claim with a nonaffirmative prior authorization tracking number, at which point the MAC would deny the claim. The ambulance provider/supplier and/or the beneficiary would then have the Medicare denial for secondary insurance purposes and would have the opportunity to submit an appeal of the claim denial if they believe Medicare coverage was denied inappropriately. • Scenario 3: When an ambulance provider/supplier or beneficiary submits a prior authorization request with incomplete documentation, a detailed decision letter will be sent to the ambulance provider/supplier and to the beneficiary, with an explanation of what information is missing. The ambulance provider/supplier or beneficiary can rectify the situation and resubmit the prior authorization request with appropriate documentation. • Scenario 4: When an ambulance provider or supplier renders a service to a beneficiary that is subject to the prior authorization process, and the claim is submitted to the MAC for payment without requesting a prior authorization, the claim will be stopped for prepayment review and documentation will be requested. ++ If the claim is determined to be not medically necessary or to be insufficiently documented, the claim will be denied, and all current policies and procedures regarding liability for payment will apply. The ambulance provider/supplier or the beneficiary or both can appeal the claim denial if they believe the denial was inappropriate. ++ If the claim is determined to be payable, it will be paid. Under the model, we will work to limit any adverse impact on E:\FR\FM\14NON1.SGM 14NON1 Federal Register / Vol. 79, No. 220 / Friday, November 14, 2014 / Notices beneficiaries and to educate beneficiaries about the process. If a prior authorization request is not affirmed, and the claim is still submitted by the provider/supplier, the claim will be denied in full, but beneficiaries will continue to have all applicable administrative appeal rights. Only one prior authorization request per beneficiary per designated time period can be provisionally affirmed. If the initial provider/supplier cannot complete the total number of prior authorized transports (for example, the initial ambulance company closes or no longer services that area), the initial request is cancelled. In this situation, a subsequent prior authorization request may be submitted for the same beneficiary and must include the required documentation in the submission. If multiple ambulance providers/suppliers are providing transports to the beneficiary during the same or overlapping time period, the prior authorization decision will only cover the provider/supplier indicated in the provisionally affirmed prior authorization request. Any provider/ supplier submitting claims for repetitive scheduled nonemergent ambulance transports for which no prior authorization request is recorded will be subject to 100 percent prepayment medical review of those claims. Additional information is available on the CMS Web site at https://go.cms.gov/ PAAmbulance. III. Collection of Information Requirements Section 1115A(d)(3) of the Act, as added by section 3021 of the Affordable Care Act, states that chapter 35 of title 44, United States Code (the Paperwork Reduction Act of 1995), shall not apply to the testing and evaluation of models or expansion of such models under this section. Consequently, this document need not be reviewed by the Office of Management and Budget under the authority of the Paperwork Reduction Act of 1995 (44 U.S.C. 35). mstockstill on DSK4VPTVN1PROD with NOTICES Authority: Section 1115A of the Social Security Act. Dated: October 8, 2014. Marilyn Tavenner, Administrator, Centers for Medicare & Medicaid Services. [FR Doc. 2014–26987 Filed 11–13–14; 8:45 am] BILLING CODE 4120–01–P VerDate Sep<11>2014 17:37 Nov 13, 2014 Jkt 235001 DEPARTMENT OF HEALTH AND HUMAN SERVICES Food and Drug Administration [Docket No. FDA–2011–N–0279] Agency Information Collection Activities; Proposed Collection; Comment Request; Prescription Drug Marketing Act of 1987; Administrative Procedures, Policies, and Requirements AGENCY: Food and Drug Administration, HHS. ACTION: Notice. The Food and Drug Administration (FDA) is announcing an opportunity for public comment on the proposed collection of certain information by the Agency. Under the Paperwork Reduction Act of 1995 (the PRA), Federal Agencies are required to publish notice in the Federal Register concerning each proposed collection of information, including each proposed extension of an existing collection of information, and to allow 60 days for public comment in response to the notice. This notice solicits comments on the information collection in the regulations on the Prescription Drug Marketing Act of 1987; Administrative Procedures, Policies, and Requirements. DATES: Submit either electronic or written comments on the collection of information by January 13, 2015. ADDRESSES: Submit electronic comments on the collection of information to: https:// www.regulations.gov. Submit written comments on the collection of information to the Division of Dockets Management (HFA 305), Food and Drug Administration, 5630 Fishers Lane, Rm. 1061, Rockville, MD 20852. All comments should be identified with the docket number found in brackets in the heading of this document. FOR FURTHER INFORMATION CONTACT: FDA PRA Staff, Office of Operations, Food and Drug Administration, 8455 Colesville Rd., COLE–14526, Silver Spring, MD 20993–0002, PRAStaff@ fda.hhs.gov. SUPPLEMENTARY INFORMATION: Under the PRA (44 U.S.C. 3501–3520), Federal Agencies must obtain approval from the Office of Management and Budget (OMB) for each collection of information they conduct or sponsor. ‘‘Collection of information’’ is defined in 44 U.S.C. 3502(3) and 5 CFR 1320.3(c) and includes Agency requests or requirements that members of the public submit reports, keep records, or provide information to a third party. SUMMARY: PO 00000 Frm 00065 Fmt 4703 Sfmt 4703 68273 Section 3506(c)(2)(A) of the PRA (44 U.S.C. 3506(c)(2)(A)) requires Federal Agencies to provide a 60-day notice in the Federal Register concerning each proposed collection of information, including each proposed extension of an existing collection of information, before submitting the collection to OMB for approval. To comply with this requirement, FDA is publishing notice of the proposed collection of information set forth in this document. With respect to the following collection of information, FDA invites comments on these topics: (1) Whether the proposed collection of information is necessary for the proper performance of FDA’s functions, including whether the information will have practical utility; (2) the accuracy of FDA’s estimate of the burden of the proposed collection of information, including the validity of the methodology and assumptions used; (3) ways to enhance the quality, utility, and clarity of the information to be collected; and (4) ways to minimize the burden of the collection of information on respondents, including through the use of automated collection techniques, when appropriate, and other forms of information technology. Prescription Drug Marketing Act of 1987; Administrative Procedures, Policies, and Requirements—21 CFR Part 203—(OMB Control Number 0910– 0435)—Extension FDA is requesting OMB approval under the PRA (44 U.S.C. 3501–3520) for the reporting and recordkeeping requirements contained in the regulations implementing the Prescription Drug Marketing Act of 1987 (PDMA). PDMA was intended to ensure that drug products purchased by consumers are safe and effective and to avoid an unacceptable risk that counterfeit, adulterated, misbranded, subpotent, or expired drugs are sold. PDMA was enacted by Congress because there were insufficient safeguards in the drug distribution system to prevent the introduction and retail sale of substandard, ineffective, or counterfeit drugs, and that a wholesale drug diversion submarket had developed that prevented effective control over the true sources of drugs. Congress found that large amounts of drugs had been reimported into the United States as U.S. goods returned causing a health and safety risk to U.S. consumers because the drugs may become subpotent or adulterated during foreign handling and shipping. Congress also found that a ready market for prescription drug reimports had been the catalyst for a continuing series of E:\FR\FM\14NON1.SGM 14NON1

Agencies

[Federal Register Volume 79, Number 220 (Friday, November 14, 2014)]
[Notices]
[Pages 68271-68273]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 2014-26987]



[[Page 68271]]

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

[CMS-6063-N]


Medicare Program; Prior Authorization of Repetitive Scheduled 
Nonemergent Ambulance Transports

AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.

ACTION: Notice.

-----------------------------------------------------------------------

SUMMARY: This notice announces a 3-year Medicare Prior Authorization 
model for repetitive scheduled nonemergent ambulance transport in the 
states of New Jersey, Pennsylvania, and South Carolina where there have 
been high incidences of improper payments for these services.

DATES: This model will begin on December 1, 2014 in South Carolina, New 
Jersey, and Pennsylvania.

FOR FURTHER INFORMATION CONTACT: Angela Gaston, (410) 786-7409. 
Questions regarding the Medicare Prior Authorization Model for 
Repetitive Scheduled Nonemergent Ambulance Transport should be sent to 
AmbulancePA@cms.hhs.gov.

SUPPLEMENTARY INFORMATION:

I. Background

    Medicare covers ambulance services, including air ambulance (fixed 
wing and rotary wing) services, when furnished to a beneficiary whose 
medical condition is such that other means of transportation are 
contraindicated. The beneficiary's condition must require both the 
ambulance transportation itself and the level of service provided in 
order for the billed service to be considered medically necessary.
    Nonemergent transportation by ambulance is appropriate if either--
(1) the beneficiary is bed-confined and it is documented that the 
beneficiary's condition is such that other methods of transportation 
are contraindicated; or (2) the beneficiary's medical condition, 
regardless of bed confinement, is such that transportation by ambulance 
is medically required. Thus, bed confinement is not the sole criterion 
in determining the medical necessity of nonemergent ambulance 
transportation; rather, it is one factor that is considered in medical 
necessity determinations.\1\
---------------------------------------------------------------------------

    \1\ 42 CFR 410.40(d)(1).
---------------------------------------------------------------------------

    A repetitive ambulance service is defined as medically necessary 
ambulance transportation that is furnished in 3 round trips or more 
times during a 10-day period, or at least once per week for at least 3 
weeks.\2\ Repetitive ambulance services are often needed by 
beneficiaries receiving dialysis, wound care, or cancer treatment.
---------------------------------------------------------------------------

    \2\ Program Memorandum Intermediaries/Carriers, Transmittal AB-
03-106.
---------------------------------------------------------------------------

    Medicare may cover repetitive, scheduled, nonemergent 
transportation by ambulance if--(1) the medical necessity requirements 
described previously are met; and (2) the ambulance provider/supplier, 
before furnishing the service to the beneficiary, obtains a written 
order from the beneficiary's attending physician certifying that the 
medical necessity requirements are met (see 42 CFR 410.40(d)(1) and 
(2)).\3\
---------------------------------------------------------------------------

    \3\ Per 42 CFR 410.40(d)(2), the physician's order must be dated 
no earlier than 60 days before the date the service is furnished.
---------------------------------------------------------------------------

    In addition to the medical necessity requirements, the service must 
meet all other Medicare coverage and payment requirements, including 
requirements relating to the origin and destination of the 
transportation, vehicle and staff, and billing and reporting. 
Additional information about Medicare coverage of ambulance services 
can be found in 42 CFR 410.40, 410.41, and in the Medicare Benefit 
Policy Manual, Chapter 10, at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c10.pdf.
    According to a study published by the Government Accountability 
Office in October 2012, entitled ``Costs and Medicare Margins Varied 
Widely; Transports of Beneficiaries Have Increased'', the number of 
Basic Life Support (BLS) nonemergent transports for Medicare fee-for-
service beneficiaries increased by 59 percent from 2004 to 2010. A 
similar finding published by the Department of Health and Human 
Services Office of Inspector General in a 2006 study, entitled 
``Medicare Payments for Ambulance Transports'', indicated a 20 percent 
nationwide improper payment rate for nonemergent ambulance transport. 
Likewise, in June 2013, the Medicare Payment Advisory Commission 
published a report \4\ that included an analysis of nonemergent 
ambulance transports to dialysis facilities and found that, during the 
5-year period between 2007 and 2011, the volume of transports to and 
from a dialysis facility increased 20 percent, more than twice the rate 
of all other ambulance transports combined.
---------------------------------------------------------------------------

    \4\ Medicare Payment Advisory Commission, June 2013, pages 167-
193.
---------------------------------------------------------------------------

    Section 1115A of the Act authorizes the Secretary to test 
innovative payment and service delivery models to reduce program 
expenditures, while preserving or enhancing the quality of care 
furnished to Medicare, Medicaid and Children's Health Insurance Program 
beneficiaries.
    Section 1115A(d)(1) of the Act authorizes the Secretary to waive 
such requirements of Titles XI and XVIII and of sections 1902(a)(1), 
1902(a)(13), and 1903(m)(2)(A)(iii) of the Act as may be necessary 
solely for purposes of carrying out section 1115A of the Act with 
respect to testing models described in section 1115A(b) of the Act. For 
these models, consistent with this standard, we will waive such 
provisions of sections 1834(a)(15) and 1869(h) of the Act that limit 
our ability to conduct prior authorization. While these provisions are 
specific to durable medical equipment and physician services, we will 
waive any portion of these sections as well as any portion of 42 CFR 
410.20(d), which implements section 1869(h) of the Act, that could be 
construed to limit our ability to conduct prior authorization. We have 
determined that the implementation of this model does not require the 
waiver of any fraud and abuse law, including sections 1128A, 1128B, and 
1877 of the Act. Thus, providers and suppliers affected by this model 
must comply with all applicable fraud and abuse laws.

II. Provisions of the Notice

    We plan to implement a 3-year Medicare Prior Authorization process 
for repetitive scheduled nonemergent ambulance transport rendered by 
ambulance providers/suppliers garaged in 3 states (New Jersey, 
Pennsylvania, and South Carolina). These states were selected as the 
initial states for the model because of their high utilization and 
improper payment rates for these services. The model will begin in on 
December 1, 2014, in South Carolina, New Jersey, and Pennsylvania.
    We plan to test whether prior authorization helps reduce 
expenditures, while maintaining or improving quality of care, using a 
model that would establish a prior authorization process for repetitive 
scheduled nonemergent ambulance transport to reduce utilization of 
services that do not comply with Medicare policy.
    We plan to use this prior authorization process to ensure that all 
relevant clinical or medical documentation requirements are met before 
services are rendered to beneficiaries and before claims are

[[Page 68272]]

submitted for payment. This prior authorization process will further 
ensure that payment complies with Medicare documentation, coverage, 
payment, and coding rules.
    The use of prior authorization will not create new clinical 
documentation requirements. Instead, it will require the same 
information that is already required to support Medicare payment, just 
earlier in the process. Prior authorization allows providers and 
suppliers to address issues with claims prior to rendering services.
    The prior authorization process under this model will be available 
for the following codes for Medicare payment:
     A0425 Ambulance service, basic life support (BLS)/advanced 
life support (ALS) ground mileage (per statute mile).
     A0426 Ambulance service, advanced life support, 
nonemergency transport, Level 1 (ALS1).
     A0428 Ambulance service, basic life support (BLS), 
nonemergency transport.
    Prior to the start of the model, we will conduct (and thereafter 
will continue to conduct) outreach and education to ambulance 
providers/suppliers, as well as beneficiaries, through such methods as 
open door forums, frequently asked questions (FAQs) on our Web site, 
other Web site postings, and educational materials issued by the 
Medicare Administrative Contractors (MACs). Additional information 
about the implementation of the prior authorization model is available 
on the CMS Web site at https://go.cms.gov/PAAmbulance.
    Under this model, an ambulance provider/supplier or beneficiary 
will be encouraged to submit to the MAC a request for prior 
authorization along with all relevant documentation to support Medicare 
coverage of a repetitive scheduled nonemergent ambulance transport. 
Submitting a prior authorization request will be voluntary. (However, 
if prior authorization has not been requested before the fourth round 
trip in a 30-day period, the claims will be stopped for pre-payment 
review).
    In order to be provisionally affirmed, the request for prior 
authorization must meet all applicable rules and policies, and any 
local coverage determination (LCD) requirements for ambulance transport 
claims. A provisional affirmation is a preliminary finding that a 
future claim submitted to Medicare for the service likely meets 
Medicare's coverage, coding, and payment requirements. After receipt of 
all relevant documentation, the MACs will make every effort to conduct 
a review and postmark the notification of their decision on a prior 
authorization request within 10 business days for an initial 
submission. Notification will be provided to the ambulance provider/
supplier and to the beneficiary. If a subsequent prior authorization 
request is submitted after a nonaffirmative decision on an initial 
prior authorization request, the MACs will make every effort to conduct 
a review and postmark the notification of their decision on the request 
within 20 business days.
    An ambulance provider/supplier or beneficiary may request an 
expedited review when the standard timeframe for making a prior 
authorization decision could jeopardize the life or health of the 
beneficiary. If the MAC agrees that the standard review timeframe would 
put the beneficiary at risk, the MAC will make reasonable efforts to 
communicate a decision within 2 business days of receipt of all 
applicable Medicare-required documentation. As this model is for 
nonemergent services only, we expect requests for expedited reviews to 
be extremely rare.
    A provisional affirmative prior authorization decision may affirm a 
specified number of trips within a specific amount of time. The prior 
authorization decision, justified by the beneficiary's condition, may 
affirm up to 40 round trips (which equates to 80 one-way trips) per 
prior authorization request in a 60-day period. Alternatively, a 
provisional affirmative prior authorization decision may affirm less 
than 40 round trips in a 60-day period, or may affirm a request that 
seeks to provide a specified number of transports (40 round trips or 
less) in less than a 60-day period. A provisional affirmative decision 
can be for all or part of the requested number of trips. Transports 
exceeding 40 round trips (or 80 one-way trips) in a 60-day period will 
require an additional prior authorization request.
    The following describes examples of various prior authorization 
scenarios:
     Scenario 1: When an ambulance provider/supplier or 
beneficiary submits a prior authorization request to the MAC with 
appropriate documentation and all relevant Medicare coverage and 
documentation requirements are met for the ambulance transport, the MAC 
will send a provisional affirmative prior authorization decision to the 
ambulance provider/supplier and to the beneficiary. When the claim is 
submitted to the MAC by the ambulance provider/supplier, it is linked 
to the prior authorization via the claims processing system and the 
claim will be paid so long as all Medicare coding, billing, and 
coverage requirements are met. However, after submission, the claim 
could be denied for technical reasons, such as the claim was a 
duplicate claim or the claim was for a deceased beneficiary. In 
addition, a claim denial could occur since certain documentation, such 
as the trip record, needed in support of the claim cannot be reviewed 
on a prior authorization request.
     Scenario 2: When an ambulance provider/supplier or 
beneficiary submits a prior authorization request, but all relevant 
Medicare coverage requirements are not met, the MAC will send a 
nonaffirmative prior authorization decision to the ambulance provider/
supplier and to the beneficiary, advising them that Medicare will not 
pay for the service. The provider/supplier or beneficiary may then 
resubmit the request with documentation showing that Medicare 
requirements have been met. Alternatively, an ambulance provider/
supplier could render the service, and submit a claim with a 
nonaffirmative prior authorization tracking number, at which point the 
MAC would deny the claim. The ambulance provider/supplier and/or the 
beneficiary would then have the Medicare denial for secondary insurance 
purposes and would have the opportunity to submit an appeal of the 
claim denial if they believe Medicare coverage was denied 
inappropriately.
     Scenario 3: When an ambulance provider/supplier or 
beneficiary submits a prior authorization request with incomplete 
documentation, a detailed decision letter will be sent to the ambulance 
provider/supplier and to the beneficiary, with an explanation of what 
information is missing. The ambulance provider/supplier or beneficiary 
can rectify the situation and resubmit the prior authorization request 
with appropriate documentation.
     Scenario 4: When an ambulance provider or supplier renders 
a service to a beneficiary that is subject to the prior authorization 
process, and the claim is submitted to the MAC for payment without 
requesting a prior authorization, the claim will be stopped for 
prepayment review and documentation will be requested.
    ++ If the claim is determined to be not medically necessary or to 
be insufficiently documented, the claim will be denied, and all current 
policies and procedures regarding liability for payment will apply. The 
ambulance provider/supplier or the beneficiary or both can appeal the 
claim denial if they believe the denial was inappropriate.
    ++ If the claim is determined to be payable, it will be paid.
    Under the model, we will work to limit any adverse impact on

[[Page 68273]]

beneficiaries and to educate beneficiaries about the process. If a 
prior authorization request is not affirmed, and the claim is still 
submitted by the provider/supplier, the claim will be denied in full, 
but beneficiaries will continue to have all applicable administrative 
appeal rights.
    Only one prior authorization request per beneficiary per designated 
time period can be provisionally affirmed. If the initial provider/
supplier cannot complete the total number of prior authorized 
transports (for example, the initial ambulance company closes or no 
longer services that area), the initial request is cancelled. In this 
situation, a subsequent prior authorization request may be submitted 
for the same beneficiary and must include the required documentation in 
the submission. If multiple ambulance providers/suppliers are providing 
transports to the beneficiary during the same or overlapping time 
period, the prior authorization decision will only cover the provider/
supplier indicated in the provisionally affirmed prior authorization 
request. Any provider/supplier submitting claims for repetitive 
scheduled nonemergent ambulance transports for which no prior 
authorization request is recorded will be subject to 100 percent 
prepayment medical review of those claims.
    Additional information is available on the CMS Web site at https://go.cms.gov/PAAmbulance.

III. Collection of Information Requirements

    Section 1115A(d)(3) of the Act, as added by section 3021 of the 
Affordable Care Act, states that chapter 35 of title 44, United States 
Code (the Paperwork Reduction Act of 1995), shall not apply to the 
testing and evaluation of models or expansion of such models under this 
section. Consequently, this document need not be reviewed by the Office 
of Management and Budget under the authority of the Paperwork Reduction 
Act of 1995 (44 U.S.C. 35).

    Authority: Section 1115A of the Social Security Act.

    Dated: October 8, 2014.
Marilyn Tavenner,
Administrator, Centers for Medicare & Medicaid Services.
[FR Doc. 2014-26987 Filed 11-13-14; 8:45 am]
BILLING CODE 4120-01-P

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