As a Medicare contractor, we want to notify you of important changes in the way Palmetto GBA will handle claims for 'Chronic Renal Disease Repetitive Ambulance Transports.' These changes were effective for claims processed on or after January 1, 2006, and affect only claims containing any of the following:
- HCPCS code A0426: Ambulance service, basic life support, nonemergency transport, Level 1 ALS 1
- HCPCS code A0428: Ambulance service, basic life support, nonemergency transport, (BLS)
- HCPCS modifier G: Hospital-based dialysis facility (hospital or hospital-related), as origin or destination
- HCPCS modifier J: Non hospital-based dialysis facility, as origin or destination
Claims Process
In order to establish a coverage period for a 'Chronic Renal Disease Repetitive Ambulance Transport' service, Palmetto GBA asks all ambulance suppliers who submit claims with the procedure code/modifier combinations listed to submit documentation with these claims, at certain intervals.
- As an ambulance provider, you will need to submit a 'parent claim.' A 'parent claim' is the first claim to define a coverage period. When this process begins, the first claim for each patient will be a parent claim. For electronic claims, you will also need to fax supporting documentation for the claim (i.e., Physician Certification Statement and any supporting documentation) via the Fax Attachment Process. When establishing a new coverage period for a patient, send the parent claim first and hold further claims (for that patient) until you receive a faxed coverage decision from Palmetto GBA.
- Other important things you should know:
- If we receive a parent claim without supporting documentation, we will send you a development letter requesting documentation
- If you do not hold your subsequent claims until you receive the parent claim coverage decision from Palmetto GBA, we will send letters to you requesting supporting documentation for each subsequent claim
- If you qualify to submit paper claims, you may choose to submit the additional supporting documentation with the claim as an attachment
- **Please be sure to indicate 'Parent Claim' in the documentation field for electronic claims and 'attachment' if paper claims are submitted
- A medical review nurse will review the parent claim and supporting documentation. A clinical decision to approve or deny the ambulance claim will be noted in the Ambulance Dialysis Tracking database. When the documentation and PCS establish medical necessity for the ambulance transport, a coverage period will be granted for either 90 days or for an indefinite period of time. The coverage decision will remain in effect for the specified time frame unless a status change is received.
- The 'parent claim' decision will be sent to you, via fax, within one business day from the time the claim decision was made. The fax form includes a contact phone number for any questions regarding the coverage decision.
- **The fax decision is a coverage decision based solely on whether coverage provisions have been met. It is possible that the claim may be denied for reasons of eligibility, entitlement, or other reasons, after the determination of coverage. Medical records and other pertinent documentation, submitted by the provider of service, will be used to make this initial claim decision.
- If the decision is a denial, you will receive a notice of denial on your remittance advice. Any pending subsequent claims that were submitted for this coverage will be denied. You may appeal the denial once you receive your remittance advice.
- If the decision is allowed, the claim is processed (approved, for 'medical review' purposes). All pending subsequent claims on file for review period will be processed.
- If the patient’s condition changes during the 'coverage period,' submit the first claim after the change occurs with supporting documentation, and include the comment 'Status Change' in the appropriate documentation field for electronic claims and an 'attachment' if paper claims are submitted
- When a subsequent claim arrives without documentation attached, we will verify whether a coverage decision is on file for the date of service
- If there is an allowed coverage decision on file for the date of service submitted, the claim will be processed (approved, for 'medical review' purposes)
- If there is a denied coverage decision on file for the date of service submitted, you will receive a notice of denial on the remittance advice. You may file an appeal.
- If there is no coverage decision in the database for the date of service submitted, we will send a letter to you requesting supporting documentation. You have up to 45 days to return the letter and any documentation to us. If documentation is not received within 45 days, the claim will be denied.
Medical Necessity
- Medical necessity is established when the patient’s condition is such that use of any other method of transportation is contraindicated
- Appropriate documentation (i.e., PCS statement, run sheet, physician documentation) must be kept on file by the ambulance service and be available to Medicare upon request
Redetermination Appeals Process
The redetermination process for 'Chronic Renal Disease Repetitive Ambulance Transport' claims will be handled in the same way as they are now in the Medical Review Department. The nurse who made the first decision will not make the redetermination decision. When a redetermination is filed, submit documentation that supports your request.
Request for Redeterminations must be submitted in writing, within 120 days of the initial determination (i.e., date on your remittance advice) and include the following:
- Patient’s name
- Medicare health insurance claim (HIC) number
- The specific service(s) and/or item(s) for which the redetermination is being requested
- The specific date(s) of service
- A legible signature of the party OR the representative of the party
- A copy of the originally requested records
- A brief explanation of why you want the claim reviewed
- Any additional information that may not have been available when the records were initially requested and examined must be enclosed
You may also submit:
- A copy of the original claim. Electronic billers should provide a paper claim copy or a complete description of the service in question.
- A copy of the Remittance Advice Notice statement
The request for redetermination, with all of the information, must be sent to the following address:
Palmetto GBA
Medicare Appeals, QA-555
P.O. Box 182933
Columbus, OH 43218-2933
- If your appeal results in a change to the coverage period (i.e., claims for dates of service during this period will be allowed as a result of the appeal), any subsequent claims that are submitted after the appeal decision will be allowed for the period identified in the appeal reversal.
Resources:
Code of Federal Regulations
- § 410.40 Coverage of Ambulance Services
- § 410.41 Requirements for Ambulance Suppliers