Beginning on January 1, 2016, Virginia will be included in a Centers for Medicare and Medicaid Services (CMS) demonstration program aimed at testing a process for seeking prior authorization for repetitive scheduled non-emergent ambulance transport.

The demonstration is currently underway in New Jersey, Pennsylvania, and South Carolina, which were chosen “because of their high utilization and improper payment rates for these services.” The demonstration program is authorized under Section 1115A of the Affordable Care Act. In addition to Virginia, Delaware, the District of Columbia, Maryland, North Carolina, and West Virginia will join the demonstration at the beginning of the new year. The program will end on December 1, 2017 for all states.

According to CMS, a repetitive ambulance service is defined as medically necessary ambulance transportation that is furnished in three or more round trips during a 10-day period, or at least one round trip per week for at least three weeks. Repetitive ambulance services are often needed by beneficiaries receiving dialysis or cancer treatment.

The prior authorization process under this model will apply for the following codes for Medicare payment:

• A0426 Ambulance service, advanced life support, non-emergency transport, Level 1 (ALS1).
• A0428 Ambulance service, BLS, non-emergency transport.

Given the potential to affect transports from nursing centers, VHCA thought you should be aware of this demonstration. Additional information about the implementation of the prior authorization model is available on the CMS Web site.