Form CMS-10708 Ambulatory Prior Authorization

OMB Control Number: 0938-NEW
Expiration Date: XX/XX/XXXX

Proposed Repetitive, Scheduled Non-Emergent Ambulance Transport (RSNAT)
Prior Authorization Process and Requirements for a Potential National Model
Under the proposed national model, submitters would have the opportunity to submit a RSNAT
prior authorization request by either mail, fax, electronic submission of medical documentation
(esMD), or through their Medicare Administrative Contractor (MAC) provider portal, if
available.
Submitters should include, at a minimum, the following data elements in a prior authorization
request package:
Beneficiary Information
• Beneficiary Name,
• Beneficiary Medicare Number,
• Beneficiary Date of Birth, and
• Beneficiary Gender
Certifying Physician/Practitioner Information
• Physician/Practitioner Name,
• Physician/Practitioner National Provider Identifier (NPI),
• Physician/Practitioner PTAN (optional), and
• Physician/Practitioner Address
Ambulance Supplier Information
• Ambulance Supplier Name
• Ambulance Supplier National Provider Identifier (NPI)
• Ambulance Supplier PTAN (optional), and
• Ambulance Supplier Address
Submitter Information
• Contact Name and
• Telephone Number
Other Information
• Number of transports requested,
• Healthcare Common Procedure Coding System (HCPCS) Code,
• Submission Date,
• Start Date,
• Indicate if the request is an initial or resubmission review,
• Indicate if the request is expedited and the reason why, and
• State where the ambulance is garaged
Additional Required Documentation
• Physician Certification Statement,

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Documentation from the medical record to support the medical necessity of repetitive
scheduled non-emergent ambulance transport,
Information on the origin and destination of the transports, and
Any other relevant document as deemed necessary by the MAC to process the prior
authorization.

Additional Information on the Number of Trips
A provisional affirmative prior authorization decision may affirm a specified number of trips
within a specific amount of time. The prior authorization decision, justified by the beneficiary’s
condition, may affirm up to 40 round trips (which equates to 80 one-way trips) per prior
authorization request in a 60-day period. Alternatively, a provisional affirmative decision may
affirm less than 40 round trips in a 60-day period, or may affirm a request that seeks to provide a
specified number of transports (40 round trips or less) in less than a 60-day period. A
provisional affirmative decision could be for all or part of the requested number of trips.
Transports exceeding 40 round trips (or 80 one-way trips) in a 60-day period would require an
additional prior authorization request.
The MAC may consider an extended affirmation period for beneficiaries with a chronic
condition that is deemed not likely to improve over time. The prior authorization decision,
justified by the beneficiary’s chronic condition, may affirm up to 120 round trips (which equates
to 240 one-way trips) per prior authorization request in a 180-day period. The medical records
must clearly indicate that the condition is chronic, and the MAC must have established through
two previous prior authorization requests that the beneficiary’s medical condition has not
changed or has deteriorated from previous requests before allowing an extended affirmation
period.

Visual Representation of the Prior Authorization Request Process

Visual Representation of the Claim Line Process if Prior Authorization was Requested

Visual Representation of the Claim Line Process if Prior Authorization was Not Requested

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improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland
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