[Federal Register Volume 80, Number 205 (Friday, October 23, 2015)]
[Notices]
[Pages 64418-64421]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2015-27030]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

[CMS-6063-N2]


Medicare Program; Expansion of Prior Authorization for Repetitive 
Scheduled Non-Emergent Ambulance Transports

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

ACTION: Notice.

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SUMMARY: This notice announces an expansion of the 3-year Medicare 
Prior Authorization Model for Repetitive Scheduled Non-Emergent 
Ambulance Transport in accordance with section 515(a) of the Medicare 
Access and CHIP Reauthorization Act of 2015. The model is being 
expanded to the states of Maryland, Delaware, the District of Columbia, 
North Carolina, West Virginia, and Virginia.

DATES: This expansion will begin on January 1, 2016 in Maryland, 
Delaware,

[[Page 64419]]

the District of Columbia, North Carolina, Virginia, and West Virginia.

FOR FURTHER INFORMATION CONTACT: Angela Gaston, (410) 786-7409.
    Questions regarding the Medicare Prior Authorization Model 
Expansion for Repetitive Scheduled Non-Emergent Ambulance Transport 
should be sent to [email protected].

SUPPLEMENTARY INFORMATION:

I. Background

    Medicare may cover ambulance services, including air ambulance 
(fixed-wing and rotary-wing) services, if the ambulance service is 
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.
    Non-emergent transportation by ambulance is appropriate if either 
the--(1) beneficiary is bed-confined and it is documented that the 
beneficiary's condition is such that other methods of transportation 
are contraindicated; or (2) 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 non-emergent ambulance 
transportation; rather, it is one factor that is considered in medical 
necessity determinations.\1\
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    \1\ 42 CFR 410.40(d)(1).
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    A repetitive ambulance service is defined as medically necessary 
ambulance transportation that is furnished in 3 or more round trips 
during a 10-day period, or at least 1 round trip per week for at least 
3 weeks.\2\ Repetitive ambulance services are often needed by 
beneficiaries receiving dialysis or cancer treatment.
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    \2\ Program Memorandum Intermediaries/Carriers, Transmittal AB-
03-106.
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    Medicare may cover repetitive, scheduled, non-emergent 
transportation by ambulance if the--(1) medical necessity requirements 
described previously are met; and (2) 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\
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    \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.
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    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 (Pub. 100-02), Chapter 10, at http://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,'' \4\ the number of 
basic life support (BLS) non-emergent 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,'' \5\ indicated a 20-
percent nationwide improper payment rate for non-emergent ambulance 
transport. Likewise, in June 2013, the Medicare Payment Advisory 
Commission published a report \6\ that included an analysis of non-
emergent 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.
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    \4\ Government Accountability Office Cost and Medicare Margins 
Varied Widely; Transports of Beneficiaries Have Increased (October 
2012).
    \5\ Office of Inspector General Medicare Payment for Ambulance 
Transport (January 2006).
    \6\ Medicare Payment Advisory Commission, June 2013, pages 167-
193.
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    Section 1115A of the Social Security Act (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 physicians' 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

    In the November 14, 2014 Federal Register (79 FR 68271), we 
published a notice entitled ``Medicare Program; Prior Authorization of 
Repetitive Scheduled Non-emergent Ambulance Transports,'' which 
announced the implementation of a 3-year Medicare Prior Authorization 
model that established a process for seeking prior authorizations for 
repetitive scheduled non-emergent 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 began on December 
1, 2014, and will end in all 3 states on December 1, 2017. Prior 
authorization will not apply to or be given for services furnished 
after that date.
    Section 515(a) of the Medicare Access and CHIP Reauthorization Act 
of 2015 (MACRA) (Pub. L. 114-10), requires expansion of the previously 
referenced prior authorization model to cover, effective not later than 
January 1, 2016, states located in Medicare Administrative Contractor 
(MAC) regions L and 11 (consisting of Delaware, the District of 
Columbia, Maryland, New Jersey, Pennsylvania, North Carolina, South 
Carolina, West Virginia, and Virginia). As such, in accordance with 
section 515(a) of MACRA, our initial expansion of the prior 
authorization model for repetitive scheduled non-emergent ambulance 
transport will include six additional states: Delaware, the District of 
Columbia, Maryland, North Carolina, Virginia, and West Virginia. This 
expansion will begin on January 1, 2016. The model will end in all 
states on December 1, 2017. Prior authorization will not apply to or be 
given for services furnished after that date.
    We will continue to test whether prior authorization helps reduce

[[Page 64420]]

expenditures, while maintaining or improving quality of care, using the 
established prior authorization process for repetitive scheduled non-
emergent ambulance transport to reduce utilization of services that do 
not comply with Medicare policy.
    We will continue to use this prior authorization process to help 
ensure that all relevant clinical or medical documentation requirements 
are met before services are furnished to beneficiaries and before 
claims are submitted for payment. This prior authorization process 
further helps to ensure that payment complies with Medicare 
documentation, coverage, payment, and coding rules.
    The use of prior authorization does not create new clinical 
documentation requirements. Instead, it requires the same information 
that is already required to support Medicare payment, just earlier in 
the process. Prior authorization allows providers and suppliers to 
address coverage issues prior to furnishing services.
    The prior authorization process under this model will apply in the 
additional six states listed previously for the following codes for 
Medicare payment:
     A0426 Ambulance service, advanced life support, non-
emergency transport, Level 1 (ALS1).
     A0428 Ambulance service, BLS, non-emergency transport.
    While prior authorization in the additional six states is not 
needed for the mileage code, A0425, a prior authorization decision for 
an A0426 or A0428 code will automatically include the associated 
mileage code.
    Prior to the start of the expansion, we will conduct (and 
thereafter will continue to conduct) outreach and education to 
ambulance providers/suppliers, as well as beneficiaries, through such 
methods as the issuance of an operational guide, frequently asked 
questions (FAQs) on our Web site, a beneficiary mailing, a physician 
letter explaining the ambulance providers/suppliers' need for the 
proper documentation, and educational events and materials issued by 
the MACs. Additional information about the implementation of the prior 
authorization model is available on the CMS Web site at http://go.cms.gov/PAAmbulance.
    Under this model, an ambulance provider/supplier or beneficiary is 
encouraged to submit to the MAC a request for prior authorization along 
with all relevant documentation to support Medicare coverage of a 
repetitive scheduled non-emergent ambulance transport. Submitting a 
prior authorization request is voluntary. However, if prior 
authorization has not been requested by 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 non-affirmative 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 non-
emergent 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 
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 because 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 non-
affirmative 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 furnish the service, and submit a claim with a non-
affirmative prior authorization tracking number, at which point the MAC 
would deny the claim. The ambulance provider/supplier and 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

[[Page 64421]]

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 not to be 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 
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 non-emergent ambulance transports for which no prior 
authorization request is recorded will be subject to 100 percent pre-
payment medical review of those claims.
    Additional information is available on the CMS Web site at http://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.

IV. Regulatory Impact Statement

    This document announces an expansion of the 3-year Medicare Prior 
Authorization Model for Repetitive Scheduled Non-Emergent Ambulance 
Transport. Therefore, there are no regulatory impact implications 
associated with this notice.

    Authority: Section 1115A of the Social Security Act.

    Dated: October 2, 2015.
Andrew M. Slavitt,
Acting Administrator, Centers for Medicare & Medicaid Services.
[FR Doc. 2015-27030 Filed 10-22-15; 8:45 am]
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