The Centers for Medicare & Medicaid Services (CMS) will begin implementing a prior authorization demonstration program for repetitive scheduled non-emergent ambulance transport in New Jersey, Pennsylvania, and South Carolina. CMS will test whether prior authorization helps reduce expenditures, while maintaining or improving quality of care. CMS believes using a prior authorization process will help ensure services are provided in compliance with applicable Medicare coverage, coding, and payment rules before services are rendered and claims are paid.
In 2012, CMS launched a prior authorization process for certain power mobility devices in seven demonstration states (California, Florida, Illinois, Michigan, New York, North Carolina, and Texas). Since implementing the demonstration, CMS has observed a decrease in expenditures for power mobility devices. CMS will leverage this success by creating a prior authorization process for certain non-emergent services under Medicare. CMS seeks to use this process to address growing concerns about beneficiaries receiving non-medically necessary repetitive scheduled non-emergent ambulance transport services. New Jersey, Pennsylvania, and South Carolina were selected for initial implementation of this process because of their high utilization and improper payment rates for these services.
Under Section 1115A of the Social Security Act, the Secretary has authority to test innovative payment and service delivery models to reduce program expenditures, while preserving or enhancing the quality of care furnished to individuals under such titles.
Prior authorization will not create new clinical documentation requirements. Instead, it will require the same information necessary to support Medicare payment, just earlier in the process. Prior authorization allows providers and suppliers to address issues with claims prior to rending services and to avoid an appeal process. This will help ensure that all relevant coverage, coding, and clinical documentation requirements are met before the service is rendered to the beneficiary and before the claim is submitted for payment.
PRIOR AUTHORIZATION PROCESS
The model will establish a prior authorization process for repetitive scheduled non-emergent ambulance transport services. This process will allow all relevant documentation to be submitted for review prior to rendering services. CMS or its contractors will review the request and provide an affirmative or non-affirmative decision. A claim submitted with an affirmative prior authorization will be paid so long as all other requirements are met. A claim submitted with a non-affirmative decision will be denied. Unlimited resubmissions are allowed. If a provider or supplier chooses to forego prior authorization and submits a claim without prior authorization decision, that claim shall undergo pre-payment review.
CMS Medicare Review Contractors will review prior authorization requests to ensure requests are consistent with all existing applicable regulations, National Coverage Determination and Local Coverage Determination requirements, and other CMS policies. Decisions on initial requests will be postmarked within 10 business days and subsequent requests will be processed within 20 business days. A provisional affirmative prior authorization decision will 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 trips) per prior authorization request in a 60-day period.
To address circumstances where applying the standard timeframe for making a prior authorization decision could seriously jeopardize the life or health of the beneficiary, CMS will include an expedited review process. The request for an expedited review must provide rationale supporting the expedited review request. Such a request must include documentation that shows that applying the standard timeframe for making a decision could seriously jeopardize the life or health of the beneficiary. In these situations, the review entity will make reasonable efforts to communicate the decision within 2 business days of receipt of all applicable Medicare required documentation.
Under this model, if a prior authorization has not been requested before the fourth round trip in a 30-day period, claims will be subject to pre-payment medical review. CMS believes that the repetitive scheduled non-emergent ambulance transport trips for a beneficiary will generally be scheduled through one provider or supplier at the beginning of the authorization period. CMS will allow one ambulance provider or supplier to request prior authorization per beneficiary per time period. Any provider or supplier submitting claims for which no prior authorization request is recorded will be subject to 100 percent medical review.