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Medicare expands prior authorization program for repetitive non-emergency transports

CMS extends the prior authorization program, through Dec. 1, 2019, to eight states and Washington DC

This article, originally published October 29, 2015, has been updated with current information about the extension of the Medicare prior authorization program for repetitive non-emergency transports.

By Ryan Stark, Doug Wolfberg and Steve Wirth

For some ambulance services, prior authorization for repetitive non-emergent trips is already a reality. For others, the Centers for Medicare and Medicaid Services (CMS) says it’s coming soon, and the agency just issued a notice extending the program that began in 2014 for eight states and the District of Columbia until December 1, 2019. The extension continues the 2016 expansion of the program from three states.

Here’s what you need to know.

A quick background on prior authorization program

CMS has an “Innovation Center” to test new payment and service delivery models that could reduce federal health care program spending. One of the Innovation Center’s initiatives is the “Prior Authorization of Repetitive Scheduled Non-Emergent Ambulance Transport Model”. Under the model, ambulance suppliers obtain prior authorization from their Medicare Administrative Contractor (MAC) for scheduled, repetitive nonemergency transports. Phase I of the model program began in South Carolina, New Jersey and Pennsylvania in December 2014.

Congress passed the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), expanding the prior authorization in two ways. First, MACRA mandated that CMS expand the prior authorization program to more states no later than Jan. 1, 2016. This is Phase 2 of the program. Second, MACRA stated that if Phase I and Phase II of the model program met certain requirements, CMS should expand the model nationwide in 2017.

Expansion happened on Jan. 1, 2016

On Oct. 23, 2015, CMS issued a notice in the Federal Register that expanded the prior authorization model to the following locations on Jan. 1, 2016:

  • Maryland
  • Delaware
  • District of Columbia
  • North Carolina
  • West Virginia
  • Virginia

If you are in these states, you need to continue prior authorization. Go to CMS’s page on Prior Authorization of Repetitive Scheduled Non-Emergent Ambulance Transport for more information.

What about the nationwide expansion of the prior authorization program?

The one thing the Oct. 23, 2015 notice failed to address is the nationwide expansion of the prior authorization program. In fact, the notice just stated that after Phase I and Phase II of the program end on Dec. 1, 2017, “Prior authorization will not apply to or be given for services furnished after that date.” So, will the program expand nationwide? It depends.

CMS is not required to go nationwide with the prior authorization program unless the program meets two primary criteria. First, the program should not reduce access to care for Medicare beneficiaries. Second, the program should save money for CMS.

Page, Wolfberg & Wirth reached out to CMS about this issue in 2015 and asked how CMS would determine this. CMS said that an evaluation contractor will look at Phase I and Phase II programs and determine whether or not the program met the two parameters. CMS did not give a specific date for when that review would happen.

However, the agency indicated that it would not expand the program nationwide until the contractor made a determination that the model program met the requisite criteria. And, if the contractor determined that the program did not meet the requirements, the contractor would recommend that the prior authorization not be expanded nationwide.

The bottom line for EMS on CMS prior authorization program for repetitive, scheduled non-emergent ambulance transports

Here’s what we know for certain as a result of the November 30, 2018 extension notice:

  • Ambulance suppliers in Delaware, District of Columbia, Maryland, North Carolina, West Virginia, Virginia, Pennsylvania, New Jersey, and South Carolina can count on the program being in place until Dec. 1, 2019.

It’s also a best practice for ambulance suppliers in remaining states to monitor for expansion of the prior authorization program. Just note that if the requirements are determined to be met and the contractor comes out with that determination after Jan. 1, 2017, the nationwide program could start later than Jan. 1, 2017. Finally, if the requirements are determined not to be met, the program likely won’t expand nationwide.

A CMS letter to physicians announcing the extension of the prior authorization program defined a repetitive ambulance service as:

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 one round trip per week for at
least 3 weeks. Medicare may cover repetitive, scheduled, non-emergent transportation by ambulance if

  • Medical necessity requirements are met, and
  • The ambulance supplier, before furnishing the service to the beneficiary, obtains a written order from the beneficiary’s attending physician certifying that those medical necessity requirements were met

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