Postpayment Service-Specific Probe Results for Ambulance Services (Emergent) for January through March 2021
Palmetto GBA performed service-specific postpayment probe review on HCPCS Code A0429 — Basic Life Support, Emergency Transport. This edit was set in North Carolina, South Carolina, Virginia and West Virginia. The results for the probe review, for claims processed January through March 2021, are presented here.
Cumulative Results
A total of 252 claims were reviewed, with 12 of the claims either completely or partially denied, resulting in an overall claim denial rate of 4.76 percent. The total dollars reviewed was $91,087.66, of which $3,780.23 was denied, resulting in a charge denial rate of 4.15 percent. Overall, there were a total of 53 auto denied claims in the region.
North Carolina Results
A total of 65 claims were reviewed, with three of the claims either completely or partially denied. This resulted in a claim denial rate of 4.62 percent. The total dollars reviewed was $23,395.47, of which $1,084.75 was denied, resulting in a charge denial rate of 4.64 percent. The top denial reasons identified, and number of occurrences based on dollars denied are:
|
Percent of Total Denials |
Denial Code |
Denial Description |
Number of Occurrences |
|---|---|---|---|
|
66.67% |
BNSIG |
Documentation Received Lacks the Necessary Beneficiary or Authorized Representative Signature |
2 |
|
33.33% |
NOTMN |
Payer Deems the Information Submitted Does Not Support Medical Necessity of the Services Billed |
1 |
South Carolina Results
A total of 13 claims were reviewed, with none of the claims completely or partially denied, resulting in a claim denial rate of 0.0 percent. The total dollars reviewed was $4,579.15, of which $0.00 was denied, resulting in a charge denial rate of 0.0 percent. There were no denial reasons identified.
Virginia Results
A total of 76 claims were reviewed, with two of the claims either completely or partially denied. This resulted in a claim denial rate of 2.63 percent. The total dollars reviewed was $28,493.07, of which $750.36 was denied, resulting in a charge denial rate of 2.63 percent. The top denial reason identified and number of occurrences based on dollars denied are:
|
Percent of Total Denials |
Denial Code |
Denial Description |
Number of Occurrences |
|---|---|---|---|
|
100.00% |
NOTMN |
Payer Deems the Information Submitted Does Not Support Medical Necessity of the Services Billed |
2 |
West Virginia Results
A total of 98 claims were reviewed, with seven of the claims either completely or partially denied. This resulted in a claim denial rate of 7.14 percent. The total dollars reviewed was $34,619.97, of which $1,945.12 was denied, resulting in a charge denial rate of 5.62 percent. The top denial reasons identified and number of occurrences based on dollars denied are:
|
Percent of Total Denials |
Denial Code |
Denial Description |
Number of Occurrences |
|---|---|---|---|
|
71.43% |
BNSIG |
Documentation Received Lacks the Necessary Beneficiary or Authorized Representative Signature |
5 |
|
28.57% |
NOTMN |
Payer Deems the Information Submitted Does Not Support Medical Necessity of the Services Billed |
2 |
Denial Reasons and Prevention Recommendations
BNSIG — Documentation Received Lacks the Necessary Beneficiary or Authorized Representative Signature
- Review documentation prior to submission to ensure that the proper beneficiary or authorized representative signature is included and is legible
- For illegible signatures, clearly print or type the full name of the owner of the signature
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 the website for links to applicable LCDs, NCDs and the E/M Scoresheet Tool for documentation requirements.
The Next Steps
The service-specific targeted medical review edits for Ambulance Services (Emergent): HCPCS Code A0429 — Basic Life Support, Emergency Transport in North Carolina, South Carolina, Virginia and West Virginia, 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, 386 KB).
Questions regarding this medical review can be directed to the Palmetto GBA Provider Contact Center at 855–696–0705.