- Ambulance Billing Guide
- Ambulance Duplicate Claim Denials
- Ambulance Transports Included in SNF Consolidated Billing
- Ambulance Physician Certification Statement Guidelines
- Prior Authorization of Repetitive Scheduled Non-Emergent Ambulance Transport
- New York State Ambulance Services in Rural Areas (for JK providers only)
- Coverage of Rural Air Ambulance Services
- Ambulance Transports Excluded from SNF Consolidated Billing
- Ambulance Medical Necessity Reminder for ESRD Patients
- Related Content
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- Claim Denials for Medically Unnecessary Ambulance Transports: Avoiding Reason Code 55B10
- Ambulance Medical Necessity
- Ambulance Rural ZIP Code Search
- Billing for A0426 or A0428
- Medical Necessity of Ambulance Services
- Proper Claim Submission for Repetitive, Scheduled, Non-Emergent Ambulance Transports
- Responsibility of Providing a Properly Executed Physician Certification Statement/Certificate of Medically Necessity
Ambulance Physician Certification Statement Guidelines
| Certification Type |
Certification Required? Yes/No | Who May Sign the Certification | Timeframe | Other Information /Resources |
|---|---|---|---|---|
| Nonemergency, scheduled, repetitive ambulance services |
Yes | Attending physician | The physician's order must be dated no earlier than 60 days before the date the service is furnished. |
|
| Nonemergency ambulance services that are either unscheduled or that are scheduled on a nonrepetitive basis— resident of a facility under a physician’s care |
Yes |
|
The physician order must be obtained within 48 hours after the transport. | If the ambulance provider or supplier is unable to obtain the required certification within 21 calendar days following the date of the service, the ambulance supplier must document its attempts to obtain the requested certification and may then submit the claim. Acceptable documentation includes a signed returned receipt from the U.S. Postal Service or other similar service that evidences that the ambulance supplier attempted to obtain the required signature from the beneficiary’s attending physician or other individual named above. |
Physician Certification Statement Requirements
A PCS is required for the following ambulance services:
- Nonemergency, scheduled, repetitive ambulance services, and
- Unscheduled, nonemergency ambulance services or nonemergency ambulance services scheduled on a nonrepetitive basis for a resident of a facility who is under the care of a physician
Note: For nonemergency, scheduled, repetitive ambulance services, the physician’s order must be dated no earlier than 60 days before the date that the service is furnished.
A PCS is not required for the following ambulance services:
- Emergency; and
- Nonemergency, unscheduled ambulance services for a beneficiary who, at the time of the transport, was residing either at home or in a facility and who was not under the direct care of a physician.
If unable to obtain the physician’s signature, it is acceptable to obtain a signed certification statement from the physician assistant, nurse practitioner, clinical nurse specialist, registered nurse, licensed practical nurse, licensed vocational nurse or social worker (where all applicable state licensure or certification requirements are met), case manager or discharge planner, who has personal knowledge of the beneficiary’s condition at the time that the ambulance transport is ordered or the service is furnished.
This individual must be employed by the beneficiary’s attending physician or by the hospital or facility where the beneficiary is being treated and from which the beneficiary is transported.
For nonemergency ambulance services that are either unscheduled or that are scheduled on a nonrepetitive basis, providers/suppliers may submit a claim after 48 hours if a PCS or certification from an acceptable alternative person as described in 42 CFR Section 410.40(a) has been obtained, or after 21 days if acceptable documentation of attempts to obtain the certification has been obtained. This policy also applies in a situation where a provider/supplier responds to a nonemergency call and upon arrival at the point-of-pickup, the condition of the beneficiary requires emergency care.
Note: Although the condition of the beneficiary in this scenario would require the provider/supplier to concentrate on the emergent treatment of the patient upon arrival at the scene, the claim for this service would not qualify as an “emergency transport.”
When a PCS cannot be obtained in accordance with 42 CFR Section 410.40(a), a provider/supplier may send a letter via USPS Certified Mail with a return receipt proof of mailing or other similar commercial service demonstrating delivery of the letter as evidence of the attempt to obtain the PCS.
Revised 3/18/2024