CMS-10708 - Supporting Statement

Supporting Statement Part A
Repetitive, Scheduled Non-Emergent Ambulance Transport (RSNAT) Prior
Authorization Model Process and Requirements
(CMS-10708/OMB control number: 0938-1380)
BACKGROUND
The Centers for Medicare & Medicaid Services (CMS) is requesting the Office of Management and
Budget (OMB) approval for the renewal of the Repetitive, Scheduled Non-Emergent Ambulance
Transport (RSNAT) Prior Authorization Model.
Prior authorization is a process through which a request for provisional affirmation of coverage is
submitted for review before the service is rendered to a beneficiary and before a claim is submitted for
payment. It helps ensure that all relevant coverage, coding, and payment requirements are met.
CMS previously tested the RSNAT Prior Authorization Model, in limited states, under the
authority of section 1115A of the Social Security Act (the Act). This model tested whether prior
authorization of RSNAT services covered under Medicare Part B lowered program spending,
while maintaining or improving the quality of care. After determining that the model met all
statutory criteria for expansion, CMS began expanding the model through multiple phases on
December 1, 2021. The model became fully operational nationwide on August 1, 2022 as the final
expansion phase was implemented.
Medicare Coverage
Medicare may cover ambulance services, including air ambulance (fixed-wing and rotary-wing)
services, if the ambulance service is furnished to a beneficiary whose medical condition is such that
other means of transportation are contraindicated. The beneficiary’s condition must require both
the ambulance transportation itself and the level of service provided in order for the billed service
to be considered medically necessary.
Non-emergent transportation by ambulance is appropriate if either the-- (1) beneficiary is
bed-confined and it is documented that the beneficiary’s condition is such that other methods of
transportation are contraindicated; or (2) beneficiary’s medical condition, regardless of bed
confinement, is such that transportation by ambulance is medically required. Thus, bed
confinement is not the sole criterion in determining the medical necessity of non-emergent
ambulance transportation; rather, it is one factor that is considered in medical necessity
determinations. 1
A repetitive ambulance service is defined as medically necessary ambulance transportation that is
furnished in 3 or more round trips during a 10-day period, or at least 1 round trip per week for at
least 3 weeks. 2 Repetitive ambulance services are often needed by beneficiaries receiving dialysis
or cancer treatment.
Medicare may cover repetitive, scheduled non-emergent transportation by ambulance if the-- (1)
medical necessity requirements described previously are met; and (2) ambulance supplier, before
1
2

42 CFR 410.40(e)(1)
Program Memorandum Intermediaries/Carriers, Transmittal AB-03-106

1

furnishing the service to the beneficiary, obtains a written order from the beneficiary’s attending
physician certifying that the medical necessity requirements are met (see 42 CFR 410.40(e)(1) and
(2)). 3
In addition to the medical necessity requirements, the service must meet all other Medicare
coverage and payment requirements, including requirements relating to the origin and destination
of the transportation, vehicle and staff, and billing and reporting. Additional information about
Medicare coverage of ambulance services can be found in 42 CFR 410.40, 410.41, and in the
Medicare Benefit Policy Manual (Pub. 100-02), Chapter 10, at
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c10.pdf.
Model History
In the November 14, 2014 Federal Register (79 FR 68271), CMS published a notice entitled
“Medicare Program; Prior Authorization of Repetitive Scheduled Non-emergent Ambulance
Transports,” which announced the implementation of a 3-year Medicare prior authorization model
under the authority of section 1115A of the Act that established a process for requesting prior
authorization for RSNAT services rendered by ambulance suppliers garaged in three states (New
Jersey, Pennsylvania, and South Carolina). These states were selected as the initial states for the
model because of their high utilization and improper payment rates for these services. The model
began on December 1, 2014, and was originally scheduled to end in all three states on December 1,
2017.
In the October 23, 2015 Federal Register (80 FR 64418), CMS published a notice titled “Medicare
Program; Expansion of Prior Authorization of Repetitive Scheduled Non-emergent Ambulance
Transports,” which announced the inclusion of six additional states (Delaware, the District of
Columbia, Maryland, North Carolina, West Virginia, and Virginia) in the RSNAT Prior
Authorization Model in accordance with section 515(a) of the Medicare Access and CHIP
Reauthorization Act of 2015 (MACRA) (Pub. L. 114-10). These six states began participation on
January 1, 2016, and the model was originally scheduled to end in all nine model states on
December 1, 2017.
In the December 12, 2017 Federal Register (82 FR 58400), CMS published a notice titled
“Medicare Program; Extension of Prior Authorization for Repetitive Scheduled Non-Emergent
Ambulance Transports,” which announced a 1-year extension of the prior authorization model in all
nine model states through December 1, 2018.
In February 2018, CMS released the model’s first interim evaluation report 4 conducted by CMS
contractor, Mathematica Policy Research, which found that that the model reduced RSNAT service
utilization, RSNAT expenditures, and total Medicare expenditures for end-stage renal disease
beneficiaries in the model states. The report did not find clear, quantitative impacts on quality,
adverse outcomes, or access to care.
In the December 4, 2018 Federal Register (83 FR 62577), CMS published a notice titled
3

Per 42 CFR 410.40(d)(2), the physician’s order must be dated no earlier than 60 days before the date the service is
furnished.
4
https://innovation.cms.gov/files/reports/rsnat-firstintevalrpt.pdf

2

“Medicare Program; Extension of Prior Authorization for Repetitive Scheduled Non-Emergent
Ambulance Transports,” which announced a 1-year extension of the prior authorization model in all
nine model states through December 1, 2019.
Section 515(b) of MACRA (Pub. L. 114-10) added paragraph (16) to section 1834(l) of the Act,
which requires that, beginning January 1, 2017, the Secretary expand the model to all states if the
model expansion meets certain statutory requirements for expanding models that are tested by the
Center for Medicare and Medicaid Innovation (Innovation Center) under the authority of section
1115A of the Act. The expansion criteria, described in paragraphs (1) through (3) of section
1115A(c) of the Act, require that:
(1) the Secretary determines that such expansion is expected to—
(A) reduce spending under applicable title without reducing the quality of care; or
(B) improve the quality of patient care without increasing spending; and
(2) the Chief Actuary of the Centers for Medicare & Medicaid Services certifies that such
expansion would reduce (or would not result in any increase in) net program spending under
applicable titles; and
(3) the Secretary determines that such expansion would not deny or limit the coverage or
provision of benefits under the applicable title for applicable individuals.
On March 28, 2018, the Chief Actuary of CMS certified 5 that expansion of the model would
reduce program spending under the Medicare program, thereby satisfying the requirements of
section 1115A(c)(2) of the Act, stating that even under the most conservative assumptions, the
projected savings from expansion would significantly outweigh the cost of administering the prior
authorization policy.
On May 29, 2019, the Secretary of the Department of Health and Human Services determined that
the model met the statutory criteria for expansion under sections 1115A(c)(1) and (c)(3) of the Act.
CMS was therefore required under section 1834(l)(16) of the Act, as added by section 515(b) of
MACRA (Pub. L. 114-10), to expand the model nationwide.
In the September 16, 2019 Federal Register (84 FR 48620), CMS published a notice titled
“Medicare Program; Extension of Prior Authorization for Repetitive Scheduled Non-Emergent
Ambulance Transports,” which announced a 1-year extension of the prior authorization model in all
nine model states through December 1, 2020.
On August 25, 2020, OMB approved the information collection burden association with the
national model under OMB control number 0938-1380.
In September 2020, CMS released the Second Interim Evaluation Report 6 conducted by CMS
contractor, Mathematica Policy Research, which found that the model was successful in reducing
RSNAT spending and total Medicare spending while maintaining overall quality of and access to
care. These findings were similar to the First Interim Evaluation Report. In comparison to groups
of similar states, the model reduced both RSNAT use and expenditures, by 63 percent and 72
https://www.cms.gov/files/document/certification-medicare-prior-authorization-model-repetitive-scheduled-nonemergent-ambulance.pdf
6
https://innovation.cms.gov/data-and-reports/2020/rsnat-secondintevalrpt
5

3

percent, respectively, in the model states, resulting in a reduction of approximately $550 million in
expenditures over four years for the population examined: beneficiaries with end-stage renal
disease, severe pressure ulcers, or both. The evaluation reports found that the prior authorization
model overall had no impact on quality measures or adverse events.
In the November 23, 2020 Federal Register (85 FR 74725), CMS published a notice titled
“Medicare Program; National Expansion of the Prior Authorization Model for Repetitive,
Scheduled Non-Emergent Ambulance Transports,” which announced the national expansion of the
RSNAT Prior Authorization Model with a delay to additional states due the COVID-19 Public
Health Emergency. The model continued to operate in the nine states that participated in the model
under section 1115A of the Act, which included Delaware, the District of Columbia, Maryland,
New Jersey, North Carolina, Pennsylvania, South Carolina, Virginia, and West Virginia.
In May 2021, CMS released the Final Evaluation Report 7 conducted by CMS contractor,
Mathematica Policy Research, which found that the model was successful in reducing RSNAT and
total Medicare spending while maintaining overall quality of and access to care over the first five
years of the model. Relative to a comparison group of similar states, the model reduced both
RSNAT service use and RSNAT expenditures, by 72% and 76%, respectively, for Medicare
beneficiaries with end-stage renal disease and/or severe pressure ulcers in the model states,
resulting in a reduction of approximately $750 million in RSNAT service expenditures relative to
the comparison group. This decrease in RSNAT service expenditures contributed to a 2.4% ($1
billion over the first five years of the model) decrease in total Medicare Fee-for-Service
expenditures among beneficiaries with end-stage renal disease and/or pressure ulcers relative to the
comparison group. Overall, the findings suggest that the model had few to no adverse effects on
quality of care or access to care.
In the August 27, 2021 Federal Register (86 FR 48149), CMS published a notice titled “Medicare
Program; National Expansion Implementation for All Remaining States and Territories of the Prior
Authorization Model for Repetitive, Scheduled Non-Emergent Ambulance Transports,” which
announced the following implementation dates for all remaining states and territories for the
national expansion of the RSNAT Prior Authorization Model:
• December 1, 2021 for independent ambulance suppliers garaged in Arkansas, Colorado,
Louisiana, Mississippi, New Mexico, Oklahoma, and Texas;
• February 1, 2022 for independent ambulance suppliers garaged in Alabama, American
Samoa, California, Georgia, Guam, Hawaii, Nevada, Northern Mariana Islands and
Tennessee;
• April 1, 2022 for independent ambulance suppliers garaged in Florida, Illinois, Iowa,
Kansas, Minnesota, Missouri, Nebraska, Puerto Rico, Wisconsin, and U.S. Virgin Islands;
• June 1, 2022 for independent ambulance suppliers garaged in Connecticut, Indiana, Maine,
Massachusetts, Michigan, New Hampshire, New York, Rhode Island, and Vermont; and
• August 1, 2022 for independent ambulance suppliers garaged in Alaska, Arizona, Idaho,
Kentucky, Montana, North Dakota, Ohio, Oregon, South Dakota, Utah, Washington, and
Wyoming.
National Model Design
The national model follows a similar design as the previous RSNAT Prior Authorization Model
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https://innovation.cms.gov/data-and-reports/2021/rsnat-finalevalrpt

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that operated under section 1115A of the Act, as described in the September 16, 2019 Federal
Register (84 FR 48620). The model applies to independent ambulance suppliers that are not
institutionally based providing Part B Medicare covered ambulance services. Hospital-based
ambulance providers owned and/or operated by a hospital, critical access hospital, skilled
nursing facility, comprehensive outpatient rehabilitation facility, home health agency, or
hospice program are not included in the model.
There are no changes to the collection requirements or forms required under this collection. The
use of prior authorization does not create new clinical documentation requirements. Instead, it
requires the same information that ambulance suppliers are already required to maintain to
support Medicare payment. Prior authorization also allows ambulance suppliers to address
coverage issues prior to furnishing services.
The prior authorization process applies to the following Healthcare Common Procedure Coding
System (HCPCS) codes for Medicare payment:
● A0426 Ambulance service, advanced life support, non-emergency transport, Level 1
(ALS1).
● A0428 Ambulance service, BLS, non-emergency transport.
While prior authorization is not needed for the mileage code, A0425, a prior authorization
decision for A0426 or A0428 will automatically include the associated mileage code.
Submitting a prior authorization request is voluntary. However, the ambulance supplier or
beneficiary is encouraged to submit a request for prior authorization along with all relevant
documentation to support Medicare coverage of a repetitive, scheduled non-emergent ambulance
transport to the Medicare Administrative Contractor (MAC). If prior authorization is not requested,
applicable RSNAT claims will be subject to a prepayment medical record review. Claims for the
first three round trips (six one-way trips) are permitted to be billed without prior authorization and
without being subject to prepayment medical record review.
In order for a prior authorization request to be provisionally affirmed, the request for prior
authorization must meet all applicable rules, including any local coverage determination (LCD)
requirements for ambulance transport claims. A provisional affirmation is a preliminary finding
that a future claim submitted to Medicare for the service likely meets Medicare’s coverage, coding,
and payment requirements. After receipt of all relevant documentation, the MAC will make every
effort to conduct a review and postmark the notification of their decision on the prior authorization
request within 10 business days. Notification will be provided to the ambulance supplier and to the
beneficiary. If a prior authorization request is non-affirmed, the request can be resubmitted with
additional documentation. Unlimited resubmissions are allowed.
An ambulance supplier or beneficiary may request an expedited review when the standard
timeframe for making a prior authorization decision could jeopardize the life or health of the
beneficiary. If the MAC agrees that the standard review timeframe would put the beneficiary at
risk, the MAC will make reasonable efforts to communicate a decision within 2 business days of
receipt of all applicable Medicare-required documentation. As this model is for non-emergent
services only, we expect requests for expedited reviews to be extremely rare.
A provisional affirmative prior authorization decision may affirm a specified number of trips within

5

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 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.
The following describes examples of various prior authorization scenarios:
● Scenario 1: When an ambulance supplier or beneficiary submits a prior authorization
request to the MAC with appropriate documentation and all relevant Medicare coverage and
documentation requirements are met for the ambulance transports, the MAC will send a
provisional affirmative prior authorization decision to the ambulance supplier and the beneficiary.
When the subsequent claim is submitted to the MAC by the ambulance supplier, it is linked to the
prior authorization decision via the claims processing system, and the claim will be paid so long as
all Medicare coding, billing, and coverage requirements are met. A claim could be denied for
technical reasons, however, such as a duplicate claim or a date of service after a deceased
beneficiary's date of death. CMS contractors may conduct targeted prepayment and post payment
reviews to ensure that claims are accompanied by documentation not required or available during
the prior authorization process. In addition, it is possible that the Comprehensive Error Rate
Testing (CERT) contractor may select a claim linked to an affirmed prior authorization decision for
review as the CERT contractor must review a random sample of claims for purposes of estimating
the Medicare improper payment rate.
● Scenario 2: When an ambulance supplier or beneficiary submits a prior authorization
request, but all relevant Medicare coverage requirements are not met, the MAC will send a
non-affirmative prior authorization decision to the ambulance supplier and to the beneficiary
advising them that Medicare will not pay for the service. The ambulance supplier or
beneficiary may then resubmit the request with additional documentation showing that
Medicare requirements have been met. Alternatively, an ambulance supplier could furnish the
service and submit a claim with a non-affirmative prior authorization tracking number, at
which point the MAC would deny the claim. The ambulance supplier and the beneficiary
would then have the Medicare denial for secondary insurance purposes and would have the
opportunity to submit an appeal of the claim denial if they think Medicare coverage was
denied inappropriately.
● Scenario 3: When an ambulance supplier or beneficiary submits a prior authorization
request with incomplete documentation, a detailed decision letter will be sent to the ambulance
supplier and to the beneficiary, with an explanation of what information is missing. The ambulance
6

supplier or beneficiary can rectify the error(s) and resubmit the prior authorization request with
appropriate documentation.
● Scenario 4: If an ambulance supplier renders RSNAT services to a beneficiary and does
not request prior authorization, then the applicable claims will be stopped for prepayment review
and documentation will be requested. Claims for the first three round trips (six one-way trips) are
permitted to be billed without prior authorization and without being subject to prepayment medical
record review.
++ If the claim is determined to be for services that were not medically necessary or for
which there was insufficient documentation, the claim will be denied, and all current policies and
procedures regarding liability for payment would apply. The ambulance supplier or the
beneficiary, or both, could appeal the claim denial if they believe the denial was inappropriate.
++ If the claim is determined to be payable, it will be paid.
Only one prior authorization request per beneficiary per designated time period can be
provisionally affirmed. If the initial ambulance supplier cannot complete the total number of prior
authorized transports (for example, the initial ambulance company closes or no longer services that
area), the initial request is cancelled. In this situation, a subsequent prior authorization request may
be submitted for the same beneficiary and must include the required documentation in the
submission. If multiple ambulance suppliers are providing transports to the beneficiary during the
same or overlapping time period, the prior authorization decision would only cover the ambulance
supplier indicated in the provisionally affirmed prior authorization request. Any additional
ambulance suppliers submitting RSNAT claims for the same beneficiary will be subject to
prepayment medical record review.

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JUSTIFICATION
1.

Need and Legal Basis

Section 515(b) of MACRA (Pub. L. 114-10) added paragraph (16) to section 1834(l) of the Act,
which requires that, beginning January 1, 2017, the Secretary expand the RSNAT Prior
Authorization Model nationally to all states if model expansion meets certain statutory
requirements for Innovation Center programs. These requirements are described in paragraphs (1)
through (3) of section 1115A(c) of the Act:
(1) the Secretary determines that such expansion is expected to—
(A) reduce spending under applicable title without reducing the quality of care; or
(B) improve the quality of patient care without increasing spending; and
(2) the Chief Actuary of the Centers for Medicare & Medicaid Services certifies that such
expansion would reduce (or would not result in any increase in) net program spending under
applicable titles; and
(3) the Secretary determines that such expansion would not deny or limit the coverage or
provision of benefits under the applicable title for applicable individuals.
Pursuant to the authority in section 515(b) of MACRA (Pub. L. 114-10), CMS is seeking to renew
the necessary approval under the PRA for the collection of information to continue operating the
RSNAT Prior Authorization Model. There are no changes to the collection requirements or
forms required under this collection.
2.

Information Users and Use

The information required under this collection will be used to determine proper payment for
repetitive, scheduled non-emergent ambulance transports. The information required in a prior
authorization request package includes all medical documents and information to show that the
number and level of transports requested are reasonable and necessary for the beneficiary and meet
other Medicare requirements. If an ambulance supplier does not submit a prior authorization request
and the claim is submitted to the MAC for payment, then the claim will be stopped for prepayment
medical record review and medical documentation will be requested. Claims for the first three round
trips (six one-way trips) are permitted to be billed without prior authorization and without being
subject to prepayment medical record review.
Trained nurse reviewers from the MAC review the information from the ambulance supplier to
determine if the beneficiary meets Medicare’s requirements for the transport and if the beneficiary
needs the level of care requested. The MAC also uses the information to determine if the number of
trips requested is reasonable and necessary.
3.

Improved Information Techniques

Some of this collection of information could involve the use of electronic or other forms of information
technology at the discretion of the submitter. Ambulance suppliers may submit their prior authorization
requests and/or other documentation through electronic means. CMS offers electronic submission of
8

medical documentation (esMD)8 and the MACs provide an electronic portal for ambulance suppliers to
submit their documentation.
4.

Duplication and Similar Information

CMS as a whole does not collect this type of information in any existing format, including the
medical documentation supporting the need for the transports. With the exception of basic
identifying information such a beneficiary name, address, etc., there is no standard form or location
where this information can be gathered.
5.

Small Businesses

This collection will impact small businesses or other entities to the extent that those small businesses
bill Medicare in a manner that triggers review under prior authorization. Ambulance suppliers
regardless of size must maintain the necessary documentation to support their claims.
6.

Less Frequent Collections

If an ambulance supplier submits a RSNAT claim without a prior authorization decision on file, the
claim will be stopped for prepayment medical record review and the ambulance supplier would submit
the documentation following receipt of an additional documentation request (ADR). Since RSNAT
services are an area of vulnerability in Medicare, less frequent collection of information on these items
under prior authorization would be imprudent and undermine the model.
7.

Special Circumstances

The frequency of the collection will vary depending on each beneficiary’s ambulance transportation
needs. Some respondents may need to report information more often than quarterly if they are
transporting beneficiaries that require RSNAT services for longer than 60 days.
8.

Federal Register Notice

A notice was published in the Federal Register on April 4, 2023 (88 FR 19956). Comments have
been addressed in Appendix 1 - Response to Public Comments.
No additional outside consultation was sought.
9.

Payments or Gifts to respondents

No payments or gifts will be given to respondents to encourage their response to any request for
information under this control number.
10.

Confidentiality

The MACs safeguard all protected health information collected in accordance with Health Insurance
8

www.cms.gov/esMD

9

Portability and Accountability Act (HIPAA) and Privacy Act standards as applicable.
Medicare contractors have procedures in place to ensure the protection of the health information provided.
The HIPAA Privacy Rule allows for the disclosure of health records for payment purposes. Data will be
kept private to the extent allowed by law.
11. Sensitive Questions
There are no questions of a sensitive nature associated with this information collection.
12.

Burden Estimate

The burden associated with the national model is the time and effort necessary for the submitter to
locate and obtain the supporting documentation for the Medicare claim and to forward the materials
to the MAC for review. CMS expects that this information would generally be maintained by
ambulance suppliers as a normal course of business and that this information would be readily
available. CMS anticipates that most submissions will be sent in through fax or by electronic
means. 9
The documentation submitted includes the medical record documentation that supports the medical
necessity of the transports, the level of care, the number of transports needed, and that Medicare
coverage requirements are met. Ambulance suppliers are currently required to maintain this
information on file. The burden for maintaining this information has not been counted for
previously.
CMS anticipates clerical staff will collect the information from the medical record and prepare it to
be submitted for review. CMS estimates that the average time for office clerical activities
associated with this task to be 30 minutes, equivalent to that for prepayment review (OMB Ctrl No
0938-0969). 10 An additional 3 hours of time is estimated for attending educational meetings and
reviewing training documents. Average labor costs (including 100 percent fringe benefits) used to
estimate the costs are calculated using data available from the Bureau of Labor
Statistics. Based on Bureau of Labor Statistics found here (Miscellaneous Healthcare Support
Occupations), we estimate an average hourly rate of $18.68 with a loaded rate of $37.26.

Based on historical model data, we estimate:
• 99 percent of prior authorization requests will be submitted electronically and 1 percent will be submitted via
mail; and
• 82 percent of ADR submissions will be submitted electronically and 18 percent will be submitted via mail.
10
The burden estimate reported here will not decrease the burden estimate or the number of prepayment reviews reported
in OMB Ctrl No 0938-0969 titled Medicare Fee-for-Service Early Review of Medical Records. RSNAT claims that
undergo prior authorization will not also undergo prepayment review. If a Medicare review contractor was conducting
prepayment review of RSNAT claims prior to the model, they would shift their resources to other claim types.
9

10

Table 1: Projected Burden for the RSNAT Prior Authorization Model
Activity

Responses Per Year
(i.e. number of
reviewed
claims) 11

Time Per
Response
(hours) or
Dollar Cost

Total Burden
Total
Burden Per Costs
Year (hours) Per Year Using
Loaded Rate

Prior Authorization Submissions - 65,012
Requests and ADR
Responses Submitted Resubmissions - 11,337
by Fax or
Electronically

0.5

32,506

$1,214,424.16

0.5

5,668.5

$211,775.16

Prior Authorization Submissions - 6,910
Requests and ADR
Responses Submitted Resubmissions - 115
by Mail

0.5

3,455

$129,078.80

0.5

57.5

$2,148.20

3

4,740

$177,086.40

Prior Authorization
Education –
Ambulance Suppliers
Prior
Authorization
Total

1,580 12

46,427

$1,734,512.72

The projected yearly burden estimate is 46,427 hours and a cost of $1.73 million. This impact is
allocated across ambulance suppliers nationally.
13.

Capital Costs

CMS estimates the cost of mailing medical records to be $5. CMS offers esMD to ambulance
suppliers who wish to use an electronic alternative for sending in medical documents. Additional
information on esMD can be found at www.cms.gov/esMD. MACs also provide an electronic portal
for ambulance suppliers to submit their documentation. Based on calendar year 2022 model data,
CMS estimates there will be 6,910 initial prior authorization requests and ADR submissions mailed
during a year. In addition, CMS estimates there will be 115 resubmission prior authorization
requests mailed following a non-affirmed decision. Therefore, the total mailing cost is estimated to
be $35,125.

The number of responses is based on calendar year 2022 model data. Submissions include initial prior authorization
requests and ADR submissions. Resubmissions include prior authorization requests resubmitted after the initial prior
authorization request was non-affirmed.
12
This number represents the number of ambulance suppliers that would potentially participate in educational trainings on
the prior authorization process. As this number does not represent responses per year, it is not included in the total
responses per year calculation.
11

11

Activity

Mailing Costs

14.

Responses Per Year
(i.e. number of
reviewed claims)
Submissions/
Resubmissions - 7,025

Time Per Response
(hours) or Dollar
Cost
$5

Total Costs
Per Year
$35,125

Costs to Federal Government

CMS estimates a yearly cost of approximately $23.2 million to operate the model with an annual 3%
inflation rate.
Our cost estimate is based on the anticipated number of prior authorization requests, both initial and
resubmissions, that would be submitted; the number of claims skipping prior authorization that would be
medically reviewed through the prepayment medical record review process; the number of potential
appeals; and the cost of outreach and education to ambulance suppliers, physicians, and beneficiaries.
15.

Changes in Burden

At the time of the last burden estimate, the model was only operational in nine states. We used
historical claims data to estimate a nationwide burden of 113,706 hours per year (based on 216,941
responses per year). The number of responses per year was calculated from the number of Medicare
Fee-for-Service beneficiaries who received RSNAT services in calendar year 2017 with the
following assumptions:
• Prior authorization requests will be submitted for 90 percent of beneficiaries receiving
RSNAT services.
• Six initial prior authorization requests will be submitted per beneficiary per year, as a prior
authorization request can be valid for up to 60 days.
• 25 percent of initial prior authorization requests will be non-affirmed and resubmitted.
• 70 percent of prior authorization requests will be submitted electronically and 30 percent will
be submitted via mail.
With the implementation of the nationwide expansion, we used the following nationwide model data
from calendar year 2022 13 in lieu of claims data to better estimate the number of responses per year:
• The number of initial prior authorization requests submitted.
• The number of resubmission prior authorization requests submitted.
• The number of ADR responses submitted.
• 99 percent of prior authorization requests were submitted electronically and 1 percent were
submitted via mail.
• 82 percent of ADR responses were submitted electronically and 18 percent were submitted
via mail.
Based on this updated data, the number of responses per year decreased from our previous estimate
of 216,941 to 83,374, which decreased the burden hours per year from 113,706 to 46,427.
If the model was operational for less than 12 months in calendar year 2022 in a state, we extrapolated to obtain a full
year’s estimate.
13

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16.

Publication or Tabulation

There are no plans to publish or tabulate the information collected.
17. Expiration Date
Each instrument displays the expiration date and OMB control number on the first page, top
right corner.

13