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Prior Authorization for Repetitive, Scheduled Non-Emergent Ambulance Transport (RSNAT) |
RSNAT Prior Authorization Form & Information
- RSNAT Prior Authorization Request Form
- RSNAT Prior Authorization Checklist Tool
- RSNAT Prior Authorization Request Form Instructions
- RSNAT Prior Authorization FAQs
- Canceling a RSNAT Unique Tracking Number (UTN)
- Requesting RSNAT Trips
- Physician Certification Statement Requirements for RSNAT
Repetitive Ambulance Service
Repetitive ambulance service is medically necessary ambulance transportation you provide with 1 of the following:
- 3 or more round trips during a 10-day period
- At least 1 round trip per week for 3 weeks
Purpose
Prior authorization allows ambulance providers and suppliers to:
- Ensure services comply with applicable Medicare coverage, coding, and payment rules.
- Address concerns prior to rendering services and submitting claims for payment.
- Know up front if claims will receive proper reimbursement.
HCPCS Codes
The following ambulance HCPCS codes are subject to prior authorization:
- A0426 (Ambulance service, Advanced Life Support (ALS), non-emergency transport, Level 1)
- A0428 (Ambulance service, Basic Life Support (BLS), non-emergency transport)
Ambulance Benefit
The Medicare ambulance benefit for non-emergent transports didn't change. Non-emergent transports are limited to patients who clinically can't transport themselves by other means. Medicare covers ambulance services for patients when:
- The medical condition is such that other means of transportation is a risk to health.
- Both the ambulance transportation itself and the level of service provided (for the billed service) is considered medically necessary.
- The transport is for a Medicare covered service at a covered destination or return from a Medicare covered service.
Documentation Requirements
Prior authorization doesn't create new documentation requirements. The following documentation is required:
- Signed Physician Certification Statement (PCS).
- Current documentation from the medical record to support medical necessity.
Additional resources:
- CMS Medicare Benefit Policy Manual (Pub. 100-02), Chapter 10
- CMS Medicare Claims Processing Manual (Pub. 100-04), Chapter 15
- 42 Code of Federal Regulations 410.40 and 410.41
Prior Authorization Process
The prior authorization process is voluntary for independent ambulance suppliers. However, if a supplier elects not to submit a prior authorization request before the 4th round trip, all related claims are subject to a prepayment medical review.
- Complete a Prior Authorization Request Form.
- Submit the completed form and relevant documentation to CGS by:
- Mail (to the address on the form)
- Fax (to the number on the form)
- Electronic Submission of Medical Documentation (esMD)
- OR, use the myCGS portal (preferred method). This option allows you to complete and submit the form, attach documents, receive a confirmation message, check status, and access decision letters electronically.
You may request up to 40 round trips in a 60-day period per prior authorization request. Suppliers and patients will receive a decision letter (affirmed or non-affirmed) within 7 calendar days.
Report the unique tracking number (UTN) identified in the decision letter on your claim. Claims submitted with a valid UTN associated with an affirmed decision will receive payment. Claims submitted with a UTN associated with a non-affirmed decision will deny. All appeals rights are then available.
For questions, email: j15bpriorautheducation@cgsadmin.com
Resources
- RSNAT Prior Authorization Model Introductory Letter
- RSNAT Prior Authorization Model Operational Guide
- Prior Authorization of Repetitive, Scheduled Non-Emergent Ambulance Transport
- MLN Fact Sheet: National Expansion of the Repetitive Scheduled Non-Emergent Ambulance Transport Prior Authorization Model
- Medical Documentation for RSNAT Prior Authorization and Claims
Updated: 01.09.2025
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