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

Seema Verma
Department of Health & Human Services
16 September 2019

[Federal Register Volume 84, Number 179 (Monday, September 16, 2019)]
[Notices]
[Pages 48620-48622]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2019-19886]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

[CMS-6063-N5]


Medicare Program; Extension 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 a 1-year extension of the Medicare Prior 
Authorization Model for Repetitive Scheduled Non-Emergent Ambulance 
Transport. The extension of this model is applicable to the following 
states and the District of Columbia: Delaware, Maryland, New Jersey, 
North Carolina, Pennsylvania, South Carolina, Virginia, and West 
Virginia.

DATES: This extension begins on December 2, 2019 and ends on December 
1, 2020.

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

SUPPLEMENTARY INFORMATION: 

I. Background

    Medicare may cover ambulance services, including air ambulance 
(fixed-wing and rotary-wing) services,

[[Page 48621]]

only 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 (OIG) 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. More 
recently, in September 2015, the OIG reported \7\ that approximately 
one in five ambulance suppliers had questionable billing, and that 
suppliers that had questionable billing provided nonemergency basic 
life support transports more often than other suppliers.
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    \4\ Government Accountability Office ``Cost and Medicare Margins 
Varied Widely; Transports of Beneficiaries Have Increased'' (GAO-13-
6) (October 2012).
    \5\ Office of Inspector General ``Medicare Payment for Ambulance 
Transport'' (January 2006).
    \6\ Medicare Payment Advisory Commission, June 2013, pages 167-
193.
    \7\ Office of Inspector General ``Inappropriate Payments and 
Questionable Billing for Medicare Part B Ambulance Transports'' 
(September 2015).
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    Section 1115A of the Social Security Act (the Act) authorizes the 
Secretary to test innovative payment and service delivery models 
expected to reduce program expenditures, while preserving or enhancing 
the quality of care furnished to Medicare, Medicaid, and Children's 
Health Insurance Program beneficiaries.
    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 under the authority of section 1115A of the Act that established 
a process for requesting prior authorization for repetitive, scheduled 
non-emergent ambulance transport rendered by ambulance suppliers 
garaged in three 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 was originally 
scheduled to end in all three states on December 1, 2017.
    In the October 23, 2015 Federal Register (80 FR 64418), we 
published a notice titled ``Medicare Program; Expansion of Prior 
Authorization of Repetitive Scheduled Non-emergent Ambulance 
Transports,'' which announced the inclusion of six additional states 
(Delaware, the District of Columbia, Maryland, North Carolina, West 
Virginia, and Virginia) in the Repetitive Scheduled Non-Emergent 
Ambulance Transport Prior Authorization model in accordance with 
section 515(a) of the Medicare Access and CHIP Reauthorization Act of 
2015 (MACRA) (Pub. L. 114-10). These six states began participation on 
January 1, 2016, and the model was originally scheduled to end in all 
nine model states on December 1, 2017.
    In the December 12, 2017 Federal Register (82 FR 58400), we 
published a notice titled ``Medicare Program; Extension of Prior 
Authorization for Repetitive Scheduled Non-Emergent Ambulance 
Transports,'' which announced a 1-year extension of the prior 
authorization model in all states through December 1, 2018.
    In the December 4, 2018 Federal Register (83 FR 62577), we 
published a notice titled ``Medicare Program; Extension of Prior 
Authorization for Repetitive Scheduled Non-Emergent Ambulance 
Transports,'' which announced a 1-year extension of the prior 
authorization model in all states through December 1, 2019.

II. Provisions of the Notice

    This notice announces that the testing of the model under section 
1115A of the Act is again being extended in the current model states of 
Delaware, the District of Columbia, Maryland, New Jersey, North 
Carolina, Pennsylvania, South Carolina, Virginia, and West Virginia for 
an additional year while we continue to work towards nationwide 
expansion under section 1834(l)(16) of the Act. The existing testing of 
the model under section 1115A authority is currently scheduled to end 
in all states on December 1, 2019; however, this notice extends the 
model under the authority in section 1115A of the Act through December 
1, 2020.
    Under this extension of the model under section 1115A authority, we 
will continue to test whether prior authorization helps reduce 
expenditures, while maintaining or improving quality of care, using the 
prior authorization process as described in 83 FR 62577. Section 
1115A(d)(1) of

[[Page 48622]]

the Act authorizes the Secretary to waive such requirements of Titles 
XI and XVIII, as well as sections 1902(a)(1), 1902(a)(13), 
1903(m)(2)(A)(iii), and 1934 (other than subsections (b)(1)(A) and 
(c)(5)) 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. Consistent with this standard, we will 
continue to waive the same provisions of Title XVIII for the extension 
of this model as have been waived for purposes of testing the model 
over the previous five years. Additionally, 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 ambulance suppliers affected by this model must comply with all 
applicable fraud and abuse laws.
    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. The 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 ambulance suppliers to address 
coverage issues prior to furnishing services.
    The prior authorization process under the extension of the model 
under 1115A authority will continue to apply in the nine 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 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.
    Under the model extension under section 1115A authority, we will 
continue our outreach and education efforts to ambulance suppliers, as 
well as beneficiaries, through such methods as updating the operational 
guide, frequently asked questions (FAQs) on our website, a physician 
letter explaining the ambulance suppliers' need for the proper 
documentation, and educational events and materials issued by the 
Medicare Administrative Contractors (MACs).
    We will continue to work to limit any adverse impact on 
beneficiaries and to educate beneficiaries about the model process. If 
a prior authorization request is non-affirmed, and the claim is still 
submitted by the ambulance supplier, the claim will be denied, but 
beneficiaries will continue to have all applicable administrative 
appeal rights. We will also continue our initiative to help find 
alternative resources for beneficiaries who do not meet the 
requirements of the Medicare repetitive scheduled non-emergent 
ambulance transport benefit.
    Additional information is available on the CMS website at http://go.cms.gov/PAAmbulance.

III. Collection of Information Requirements

    Section 1115A(d)(3) of the 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 a 1-year extension of the 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: August 22, 2019.
Seema Verma,
Administrator, Centers for Medicare & Medicaid Services.
[FR Doc. 2019-19886 Filed 9-13-19; 8:45 am]
BILLING CODE 4120-01-P