RSNAT Prior Authorizations and the PCS

by Rebecca Illig, QMC Compliance Manager

In 2014…

In 2014 CMS initiated a Repetitive Scheduled Non-Emergency Ambulance Transportation (RSNAT) prior authorization demonstration program for certain states. These included South Carolina, New Jersey, and Pennsylvania. The program was expanded in December of 2015 by CMS to include Delaware, the District of Columbia, Maryland, North Carolina, Virginia, and West Virginia.

Following a review which noted savings in the millions of dollars, for the Medicare program with no negative affect on beneficiary health, the decision was made in September of 2020 to take this process nationwide. December 1^st, 2021 saw the next phase of the expansion that included Arkansas, Colorado, Louisiana, Mississippi, New Mexico, Oklahoma, and Texas. More recently (February 1^st, 2021), Alabama, American Samoa, California, Georgia, Guam, Hawaii, Nevada, and the Northern Mariana Islands were added into the mix. The balance of the nation will see expansion over the remaining months of 2022.

A Confusing Overlap

One area of the Prior Authorization program that causes confusion rests with the overlap between prior authorization and the required Physician Certification Statement (PCS). Here we attempt to clarify the confusion.

So, what is a prior authorization?

According to the CMS’ guidelines it is “a process through which a request for provisional affirmation of coverage is submitted for review before a service is rendered to a beneficiary and before a claim is submitted for payment”. The prior authorization helps to make sure that applicable coverage, payment and coding rules are met before the repetitive non-emergent ambulance transport service is rendered. Some insurance companies (TRICARE, certain Medicaid programs, and the private sector) are already using prior authorizations. Every Medicare Administrative Contractor (MAC) has their own version of the request form – this form needs to be used and sent in with the patient’s medical records (not just the Patient Care Report!) in order to obtain the prior authorization.

The Prior Authorization Form

Using the appropriate form (supplied by the MAC) the prior authorization request can be mailed, faxed, submitted through the MAC provider portal, or submitted through the Electronic Submission of Medical Documentation (esMD) system. The request needs to identify:

All information found on the MAC’s request form. Some of these include but are not limited to, beneficiary’s name, Medicare Number, and date of birth. Procedure codes, submission date, and number of transports requested.
The Physician Certification Statement
Documentation from the medical record to support the medical necessity of the transports: Clear description of the patient’s current condition, supporting the need for transport, dated prior to the date of the transport. This information must be from the patient’s clinician, not the ambulance provider!
The origin and destination of the transports
Any other relevant document as deemed necessary by the MAC to process the prior authorization

The PCS

The PCS or Physician Certification Statement is a statement signed and dated by the beneficiary’s attending physician which certifies that the medical necessity provisions are met. Repetitive patients are required to have a signed and dated PCS from their physician (MD or DO) only, any other additional authorized signer is not valid for repetitive patients! This statement does not need to be a specific form. If the “form” has the necessary information, it would qualify as a PCS. For example, a written letter signed and dated by the patient’s attending physician describing the patient’s condition to support the need for ambulance transport.

Do you need both?

At some point, all states will be required to obtain a prior authorization for repetitive scheduled non-emergent transports in order to receive payment (*see link below for the implementation dates). However, it is not required to have a prior authorization to bill a claim to Medicare. If the agency does not have a prior auth, all the patient’s repetitive trips will be reviewed by the MAC prior to payment. A Certificate of Medical Necessity is always required for unscheduled (PCS or N-PCS) and scheduled (PCS only) non-emergent transports in order to bill Medicare/Medicare HMOs for payment.

Remember that the Physician Certification Statement is only valid for 60 days from the date signed! This means the PCS form can expire during the timeframe the prior authorization is still active. A new PCS form (signed by the beneficiary’s attending physician) will need to be obtained in order to bill those claims to Medicare.

No Payment Guarantee

My EMS agency has both, does that mean Medicare has guaranteed to pay these claims?

No, even though you may have a prior authorization and a valid PCS on file, that does not mean Medicare has agreed to pay those claims. It simply means that the MAC feels this beneficiary meets their medical necessity requirements. Your agency is still required to document the patient’s condition at the time of transport to support why that patient is unable to be transported by other means (i.e., wheelchair van, stretcher van, or personal vehicle) or why the patient requires a medical attendant.

Explain Why (and ditch the trigger phrases!)

Watch out for trigger phrases! The statement “patient needs transport by ambulance because they are bed-confined” alone does not support medical necessity! Remember to explain WHY! Why is the patient bed-confined? Why do they need to go by ambulance? Why can’t they sit in a wheelchair for the duration of transport? Why does this patient require supervision by a medical attendant?

Helpful Links

RSNAT Prior Authorizations and the PCS