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Temporary CMS changes provide needed flexibility

CMS has relaxed ambulance regulations and rules to assist EMS agencies nationwide during the public health emergency


CMS is starting to relax some of the statutory requirements and payment polices to allow EMS agencies and ambulance services to better cope with the COVID-19 public health emergency, and to focus less on “paperwork” and administrative burdens.

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Steve Wirth, Esq., EMT-P; and Ryan Stark, Esq.

By Steve Wirth, Esq., EMT-P; and Ryan Stark, Esq.

The Centers for Medicare and Medicaid Services (CMS) announced on Mar. 30, 2020, that it is making major changes to help EMS agencies and ambulance services during the COVID-19 pandemic. CMS will allow Medicare to pay for transports to alternative destinations; pause the repetitive, scheduled non-emergency prior authorization program; suspend most Medicare audits; and extend appeal deadlines during the COVID-19 public health emergency.

These latest positive developments from CMS were announced in an Interim Final Rule and other CMS directives and guidance in response to the crisis. CMS is starting to relax some of the statutory requirements and payment polices to allow EMS agencies and ambulance services to better cope with the COVID-19 public health emergency, and to focus less on “paperwork” and administrative burdens.

Reimbursement for EMS transports to alternative destinations

During the COVID-19 public health emergency, CMS will expand the list of Medicare-covered destinations to include all destinations that are equipped to treat the condition of the patient consistent with EMS protocols established by state and/or local laws where the services will be furnished. Approved alternative destinations may include, but are not limited to:

  • Any location that is an alternative site determined to be part of a hospital, critical access hospital or skilled nursing facility
  • Community mental health centers
  • Federal qualified health clinic
  • Rural health clinics
  • Physicians’ offices
  • Urgent care facilities
  • Ambulatory surgery centers
  • Any location furnishing dialysis services outside of an end-stage renal disease (ESRD) facility when an ESRD facility is not available
  • The beneficiary’s home

This destination expansion applies to emergency and non-emergency ground ambulance transports of beneficiaries from any point of origin during the public health emergency for COVID-19. This list of covered alternative destinations during the pandemic applies to all types of ambulance services in the U.S. that bill Medicare.

Ordinarily, Medicare would only reimburse for transports to “covered destinations” such as hospitals, critical access hospitals and skilled nursing facilities. The expanded list recognizes the unprecedented strain on our healthcare system that is now occurring, and the reality that patients may be appropriately treated at a non-hospital or other destinations due to the massive overcrowding seen in hospital emergency departments in many areas of the country. CMS has not issued additional guidance on destination modifiers to be used during the billing process, and these temporary changes do not waive medically necessary requirements for transports to these alternative destinations.

Another consideration: Some state EMS regulations expressly state that ambulances may only transport 911 patients to hospital emergency departments. So, to operationalize these new Medicare regulations, you should check with your state EMS office. A state may need to enact an emergency rule or a waiver to allow for these alternative destinations.

CMS pausing non-emergency prior authorization model

Effective Mar. 29, 2020, the repetitive, scheduled non-emergent ambulance transport prior authorization model will be paused in the model states of Delaware, the District of Columbia, Maryland, New Jersey, North Carolina, Pennsylvania, South Carolina, Virginia and West Virginia until the Public Health Emergency for the COVID-19 pandemic has ended.

During the pause, claims for repetitive, scheduled non-emergent ambulance transports submitted on or after Mar. 29, 2020, and before the end of the public health emergency will not be stopped for pre-payment review if prior authorization has not been requested by the fourth round trip in a 30-day period. Medicare Administrative Contractors (MACs) that administer Medicare claims will continue to review any prior authorization requests that have already been submitted, and ambulance services may continue to submit new prior authorization requests for March 2020 review during the pause.

CMS suspends most Medicare audits

More good news! CMS has also suspended most Medicare Fee-For-Service medical reviews during the emergency period due to the COVID-19 pandemic. This includes pre-payment medical reviews conducted by MACs under the Targeted Probe and Educate program, and post-payment reviews conducted by MACs, Supplemental Medical Review Contractors reviews and Recovery Audit Contractors.

No additional documentation requests will be issued during the COVID-19 Public Health Emergency. Targeted Probe and Educate reviews that are in process will be suspended and claims will be released and paid. Current post-payment reviews will be suspended and released from review. This suspension of medical review activities is for the duration of the public health emergency. However, CMS may conduct medical reviews during or after the Emergency if there is an indication of potential fraud.

Relaxing Medicare appeal rules

CMS is also allowing the MACs and qualified independent contractors (QICs) to permit extensions to file appeals of denied Medicare claims. This includes the authority to waive requests for timeliness requirements for additional information to adjudicate appeal. CMS is also allowing MACs and QICs to process an appeal even with incomplete Appointment of Representation forms as normally required. However, if an Appointment of Representation form is missing or lacking, all communications will be sent to the Medicare patient, and not the provider or supplier. CMS is also allowing MACs and QICs to utilize “all flexibilities available” in the appeal process as if “good cause” requirements for missing a deadline are satisfied.

Other COVID-19 initiatives to watch for

Watch for these initiatives as well:

  • Patient signature rules. The American Ambulance Association and Page, Wolfberg & Wirth have reached out to CMS to request that it waive the requirement that ambulance services obtain an assignment of benefits signature during this crisis, due, in part, to the high degree of potential infections with patients touching pens and devices to sign their name. While very receptive to this request, as of the writing of this article, CMS has not issued any formal, written guidance modifying the current signature requirements.
  • Medical necessity for COVID-19 patients. The AAA, PWW and other ambulance industry partners have also requested that CMS relax the ambulance medical necessity rules during the public health emergency. Specifically, stakeholders are requesting that CMS issue guidance stating that the medical necessity requirements for an ambulance transport are met on the basis that suspected and confirmed COVID-19 patients transported by ambulance require strict isolation and infection control procedures to be in place for the protection of the crew and the patient. Our strong contention is that these patients cannot be safely transported by means other than an ambulance, because other vehicles simply do not have the infection control capabilities of an ambulance to properly deal with COVID-19. We are awaiting more from CMS on this request.
  • Reimbursement for treatment in place and telehealth. Additional reimbursement for ambulance services? We could also see additional reimbursement opportunities for ambulance services for treatment in place and telehealth during the public health emergency. Several industry groups have asked that CMS allow reimbursement to occur for these non-traditional ambulance services that are now critically necessary due to COVID-19 and the strain on traditional medical resources. In effect, this would put in place, for all ambulance providers and suppliers, the payment provisions outlined in the ET3 alternative payment model that CMS was on the cusp of initiating as a pilot project with over 200 ambulance services around the country. Again, we hope to hear more from CMS on this important request.

Additional resources on CMS COVID-19 changes

Find more information on Medicare COVID-19 waivers and flexibilities with these resources:

About the authors

Steve Wirth and Ryan Stark are partners in the national EMS law firm of Page, Wolfberg & Wirth, LLC and are highly regarded EMS attorneys, authors and speakers. They can be reached at and

For over 20 years, PWW has been the nation’s leading EMS industry law firm. PWW attorneys and consultants have decades of hands-on experience providing EMS, managing ambulance services and advising public, private and non-profit clients across the U.S.

PWW helps EMS agencies with reimbursement, compliance, HR, privacy and business issues, and provides training on documentation, liability, leadership, reimbursement and more. Visit the firm’s website at