01-015 Non-Emergency Ambulance Notification of Medical Review

Noridian Healthcare Solutions, LLC, as the Supplemental Medical Review Contractor (SMRC) for the CMS, is conducting post-payment review of claims for non-emergency ambulance services billed on dates of service from January 1, 2018, through December 31, 2018. This notification includes the reasons for the review, documentation that will be requested in the Additional Documentation Request (ADR) letter, and resources providers/suppliers may wish to consult when submitting claims.

Background

The Office of Inspector General (OIG) report A-09-17-03018, dated July 2018 entitled “Medicare Improperly Paid Providers for Non-Emergency Ambulance Transports to Destinations Not Covered by Medicare,” focused on calendar years (CY) 2014 through 2016 to determine whether Medicare payments to providers for non-emergency ambulance transport complied with Federal requirements. The OIG found that Medicare made improper payments of $8.7 million to providers for non-emergency ambulance transports to destinations not covered by Medicare, including the identified ground mileage associated with the transports. The total improper payment amount of $8.7 million included claim lines outside of the 4-year claim-reopening period. The objective of the report was to determine whether Medicare payments to providers for non-emergency ambulance transports complied with Federal requirements.

Reason for Review

In response to the OIG study, the CMS provided the SMRC a file of national provider identifiers (NPI) specifically identified by the OIG, while conducting the original study. The SMRC will perform medical record review for the specified NPIs to determine if the non-emergency ambulance transports were reasonable and necessary for the level of service billed in accordance with applicable statutory, regulatory, and sub-regulatory guidance.

Claim Sample Detail

HCPCS
  • A0425: Ground Mileage, per statute mile
  • A0426: Ambulance service, ALS, non-emergency transport, level 1
  • A0428: Ambulance service, BLS, non-emergency transport

Access related project details below.

Documentation Requirements

Below is a list of specific documentation requirements that will be included in each ADR to obtain the necessary documentation to perform the review. Documentation requested has been made specific to assist the provider in collecting and submitting pertinent information to decrease provider burden.

  1. Ambulance dispatch report/trip log to support the beneficiary’s medical condition for the billed service and to provide documentation of the level of care provide by ambulance personnel including, but not limited to:
    1. Correct Beneficiary and Date of Service
    2. Physician Certification Statement (PCS)
    3. Documentation to support the non-emergent transport of the beneficiary
    4. Reason for the transport
    5. Assessment and clinical evaluations which describe the beneficiary’s condition and functional status at the time of transfer
    6. Description of monitoring and treatments required and performed/administered
    7. Point of pick up/destination (place and complete address)
    8. Identification of crew members and credentials
    9. Documentation supporting the number of loaded miles billed
    10. Documentation to support that the beneficiary was transported to the nearest appropriate facility
    11. Documentation to support assignment of benefits including beneficiary signature or signature of representative
  2. Valid electronic or handwritten signatures, when applicable
  3. Copies of any patient notices given (e.g., Advance Beneficiary Notice of Noncoverage (ABN)), if applicable

References/Resources

  • Social Security Act (SSA) Title XVIII, Section §1833(e). Payment of Benefits
  • Social Security Act (SSA) Title XVIII, Section §1861(s)(7). Medical and Other Health Services; Ambulance
  • Social Security Act (SSA) Title XVIII, Sections §1862(a)(1)(A). Exclusions from Coverage and Medicare as Secondary Payer
  • Social Security Act (SSA) Title XVIII, Sections §1879(879(a)(1), (g)(2). Limitation on Liability of Beneficiary where Medicare Claims are Disallowed
  • Social Security Act (SSA) Title XVIII, Section 1893 (b). Medicare Integrity Program.
  • Code of Federal Regulations Title 42, Section 410.40(a-f). Coverage of Ambulance Services
  • Code of Federal Regulations Title 42, Section 424.36(b) (1-4). Signature Requirements
  • Medicare Benefit Policy Manual, Publication 100-02, Chapter 10, Section 10.2.1. Necessity for the Service
  • Medicare Benefit Policy Manual, Publication 100-02, Chapter 10, Section 10.2.2. Reasonableness of the Ambulance Trip
  • Medicare Benefit Policy Manual, Publication 100-02, Chapter 10, Section 10.2.3. Medicare Policy Concerning Bed-Confinement
  • Medicare Benefit Policy Manual, Publication 100-02, Chapter 10, Section 10.2.4. Documentation Requirements
  • Medicare Benefit Policy Manual, Publication 100-02, Chapter 10, Section 10.2.6. Effect of Beneficiary Death on Medicare Payment for Ground Ambulance Transports
  • Medicare Benefit Policy Manual, Publication 100-02, Chapter 10, Section 10.3. The Destination
  • Medicare Benefit Policy Manual, Publication 100-02, Chapter 10, Section 10.3.6. Appropriate Facilities
  • Medicare Benefit Policy Manual Publication 100-02, chapter 10, Section 10.3.8. Ambulance Service to Physician’s Office
  • Medicare Benefit Policy Manual, Publication 100-02, Chapter 10, Section 30.1.1. Ground Ambulance Services
  • Medicare Claims Processing Manual, Publication 100-04, Chapter 15. Ambulance
  • Medicare Program Integrity Manual (PIM), Publication 100-08, Chapter 3, Section 3.2.3.8. No response of Insufficient Response to Additional Documentation Requests
  • Medicare Program Integrity Manual (PIM), Publication 100-08, Chapter 3, Section 3.3.2.4. Signature requirements
  • Medicare Program Integrity Manual (PIM), Publication 100-08, Chapter 3, Section 3.3.2.8. MAC Articles
  • Medicare Program Integrity Manual (PIM), Publication 100-08, Chapter 3, Section 3.6.2.2. Reasonable and necessary criteria
  • Local Coverage Determination (LCD) L34549. Ambulance Services. Effective 10/01/2015-present.
  • Local Coverage Determination (LCD) L35162. Ambulance Services. Effective 10/01/2015-present.
  • Local Coverage Determination (LCD) L37697. Transportation Services: Ambulance. Effective 06/28/2018-present
  • Local Coverage Article (LCA) A52588: Billing for Ground Ambulance Services When the Beneficiary is Pronounced Deceased. Effective 10/01/2015-present
  • Local Coverage Article (LCA) A52594: Emergency and Non-Emergency ground Ambulance services New Part A and Part B. Effective 10/01/2015-present
  • Local Coverage Article (LCA) A54574: Ambulance Services (Ground Ambulance). Effective 10/01/2015-present
  • Local Coverage Article (LCA) A55096: Reminder Regarding Ambulance Transports- Dual Diagnoses (Provider Bulletin). Effective 6/9/2016-present
  • Local Coverage Article (LCA) A55975: A0425 Non-Emergency ground Ambulance services. Effective 06/28/2018-present
  • Local Coverage Article (LCA) A55976: Response to Comments: Emergency and Non-Emergency Ground Ambulance Services. Effective 6/28/2018-present
  • Local Coverage Article (LCA) A56043: Non-Emergency Ground Ambulance Services retired Part A and Part B LCD. Effective 6/28/2018-present
  • Local Coverage Article (LCA) A56070: Emergency and Non-Emergency ground Ambulance services revision to the Part A and Part B LCD. Effective 07/16/2018-present
  • Local Coverage Article (LCA) A56130: Emergency and Non-Emergency ground Ambulance services revision to the Part A and Part B LCD. Effective 09/09/2018-present

Last Updated Jun 24, 2019