Postpayment Service-Specific Probe Results for Ambulance Service, Advanced Life Support, Non-Emergency Transport Level 1 for January through March 2021

Palmetto GBA performed service-specific post payment probe review on HCPCS Code A0426 — Ambulance Services, Advanced Life Support, Non-Emergent Transport, Level 1. This edit was set in Alabama, Georgia and Tennessee. The results for the postpay review, for claims processed January through March, 2021, are presented here. Overall, there were no auto-denied claims in the region.

Cumulative Results
A total of 74 claims were reviewed in Alabama, Georgia and Tennessee combined. Of the claims reviewed, nine of the claims were either completely or partially denied, resulting in an overall claim denial rate of 12.16 percent. The total dollars reviewed was $19,684.93, of which $1,053.40 was denied, resulting in a charge denial rate of 5.35 percent.

Alabama Results
A total of one claim was reviewed in Alabama, which was neither completely nor partially denied, resulting in a claim denial rate of 0.0 percent. The total dollars reviewed was $262.29 of which $0.00 was denied, resulting in a charge denial rate of 0.0 percent.

Georgia Results
A total of 49 claims were reviewed in Georgia, with four of the claims either completely or partially denied. This results in a claim denial rate of 8.16 percent. The total dollars reviewed was $12,930.38, of which $613.61 was denied, resulting in a charge denial rate of 4.75 percent. The top denial reasons identified, and number of occurrences based on dollars denied are: 

Tennessee Results
A total of 24 claims were reviewed in Tennessee, with five of the claims either completely or partially denied. This resulted in a claim denial rate of 20.83 percent. The total dollars reviewed was $6,492.26, of which $439.79 was denied, resulting in a charge denial rate of 6.77 percent. The top denial reasons identified, and number of occurrences based on dollars denied are: 

Denial Reasons and Prevention Recommendations

NOTMN — Payer Deems the Information Submitted Does Not Support the Medical Necessity of the Services Billed

• Ensure that all documentation to support medical necessity of the service billed is submitted for review. This includes original chart notes and any diagnostic, radiological or laboratory results.
• Verify that documentation to support the level of service billed is included. Please refer to our website for links to applicable LCDs and NCDs for documentation requirements

The Next Steps
The service-specific postpayment medical review edits for HCPCS Code A0426 — Ambulance Services, Advanced Life Support, Non-Emergent Transport, Level 1 in Alabama, Georgia and Tennessee will be continued based on moderate charge denial rates and medium to high impact severity errors. If significant billing aberrancies are identified, provider-specific review may be initiated.

If you are dissatisfied with a claim determination you have the right to request an appeal. Palmetto GBA encourages you to review the documentation originally submitted, and if you believe you have additional supporting documentation you may include this information with your appeal. For more information related to the appeals process please refer to the Redetermination 1st Level Appeal form (PDF, 406 KB). Questions regarding this medical review can be directed to the Palmetto GBA Provider Contact Center at 877–567–7271.