CMS-10708 Ambulatory Prior Authorization

OMB Control Number: 0938-1380
Expiration Date: XX/XX/XXXX

Repetitive, Scheduled Non-Emergent Ambulance Transport (RSNAT) Prior
Authorization Process and Requirements
Submitters may 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.
Submitters should include, at a minimum, the following data elements in a prior authorization
request package:
Beneficiary Information
• Beneficiary Name,
• Beneficiary Medicare Number, and
• Beneficiary Date of Birth.
Certifying Physician/Practitioner Information
• Physician/Practitioner Name,
• Physician/Practitioner National Provider Identifier (NPI),
• Physician/Practitioner Provider Transaction Access Number (PTAN) (optional), and
• Physician/Practitioner Address.
Ambulance Supplier Information
• Ambulance Supplier Name,
• Ambulance Supplier NPI,
• Ambulance Supplier PTAN (optional), and
• Ambulance Supplier Address.
Submitter Information
• Contact Name and
• Telephone Number.
Other Information
• Number of one-way transports requested 1,
• Healthcare Common Procedure Coding System (HCPCS) Code,
• Submission Date,
• Requested start date of the prior authorization period,
• 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,

1

One round trip equals two one-way trips.

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Documentation from the medical record to support the medical necessity of the repetitive
scheduled non-emergent ambulance transports,
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