Prior Authorization

Submitting a Prior Authorization Request

Table of Contents

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Submitting a Prior Authorization Request

Ambulance suppliers or beneficiaries should legibly complete the National Government Services Prior Authorization Request for Repetitive, Scheduled Non-Emergent Ambulance Transports. The Cover Sheet is now available and it's also available on our Forms page. 

Please be sure to include the following information in your request.

  • The beneficiary's first and last name, MBI, and date of birth
  • The certifying physician's name, NPI, PTAN (optional), and address
  • The ambulance supplier's name, NPI, PTAN (optional) and address
  • The requestor's contact name, telephone number and submission date
  • The number of transports required
  • HCPCS code (A0426, A0428)
  • Requested start date of prior authorization period
  • Include whether the request is an initial or resubmission review
  • Indicate if the request is expedited and the reason why and
  • The state where the ambulance is garaged

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Documentation Requirements

Please ensure all of the following relevant documentation is included with the original prior authorization submission:

  • Physician Certification Statement – see regulations at 42 CFR Section 410.40(a)
  • Number of transports requested
  • Medical record documentation to support medical necessity
  • Origin and destination information
  • Any other relevant documentation deemed necessary by NGS to process the prior authorization

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Documentation Checklist for Medical Professionals

  • Medical record requirements.
  • The record is specific to the date of service that contains objective observations from a patient encounter.
    • Examples: Hospital records, doctors’ and ancillary staff progress notes, SNF records, dialysis facility documents, plan of care, interdisciplinary notes, physical or occupational therapy progress notes, etc.
  • The record is current. The date of service for the record is on, or prior to, the start date requested and transport occurs.
  • Each page must include the patient identification information (complete name, date(s) of service[s].
  • The name, credentials, and signature (handwritten or electronic) of rendering physician or NPP treating the patient must be included.
  • Every page of the record is legible and readable.

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Supporting the Physician Certification Statement

The record must support a medical condition(s) on the PCS.

Statements such as, “patient reports shortness of breath,” “hypertension,” “generalized weakness,” “bed-confined,” etc., must include the supporting clinical assessment data to justify Medicare payment for ambulance services.

Revised 4/12/2022