Beginning with dates of service on or after December 15, 2014, providers of Medicare Part B covered ambulance services in South Carolina, New Jersey and Pennsylvania will be required to obtain prior-authorization before Original Medicare will cover certain medically necessary non-emergency ambulance rides. The new prior authorization requirements are part of a three-year demonstration. Repetitive ambulance rides are commonly used by patients receiving kidney dialysis or certain cancer treatments, and they are defined as ambulance rides provided to patients three or more times during a ten-day period, or rides provided at least once a week for three or more weeks.

Through this demonstration, CMS hopes to address what they view as a higher than usual rate of ambulance billing fraud in these three states. Upon request, beneficiaries receiving non-emergency ambulance rides will be notified whether Medicare will pay for their non-emergency transportation in advance. Otherwise, the ambulance provider will be notified. Requiring prior authorization is a contrast to procedures that apply in Original Medicare, where beneficiaries receiving non-emergency ambulance transportation can be impacted by unexpected ambulance costs when those claims are denied as not meeting Medicare’s coverage requirements, after services have already taken place.

Individuals who rely on non-emergency ambulance transportation are often more medically vulnerable and frail than other Medicare beneficiaries. It is important that beneficiaries, providers and their advocates proactively work to ensure prior-authorization is obtained and any problems are addressed in a timely manner.