Non-emergency Ambulance Services: Regulations and Required Documentation Webcast - Questions and Answers

The following questions were received during our March 20, 2018, Non-emergency Ambulance Services: Regulations and Required Documentation webcast.

Q. When performing eligibility search outside of the Medicare system, how will I know it is RR Medicare since the R is going away? I am concerned about the submission of claims going to the incorrect address. 
A. The new cards will have the Railroad Retirement Board (RRB) logo on them.

Q. Ambulance transports typically do not get a copy of the card due to emergencies or lack of equipment to scan. Other thoughts?  I currently access Medicare eligibility through an eligibility vendor search.
A.
Starting on 4/1/18, CMS will return a message on the electronic eligibility transaction response for Railroad Medicare patients that will say 'Railroad Retirement Medicare Patient'.

Some options are going to be to verify how you are receiving that information now. Are you getting that information through an eligibility vendor? Vendors that use the HIPAA Eligibility Transactions System (HETS) right now will be able to return a message starting in April of 2018, and throughout the transition period, whenever you check eligibility status. HETS will return a message that says “CMS mailed a Medicare card with the new Medicare Beneficiary Identifier number or MBI to this beneficiary. Medicare providers please get the new MBI from your patient and save it in your system.” That message will get returned to you in 271 loop 2110C segment MSG.  If you don’t do your own eligibility transactions, if you have a vendor or service provider that is doing that for you who would understand the loop and segment information message, check with them and verify how they are getting the information now and what their plan is going forward for providing that information to you. They can tell you whether or not they are using HETS so they will know whether they will get this message back on the eligibility transactions and how they plan to give you this information. 

We encourage you to think about, if you have not already, signing up for our eServices portal. Starting in June of 2018, when you can’t get the MBI number from the patient or the patient does not have the MBI to give you, you can look up their MBI through the MACs’ secure portals. This is for all Medicare contractors including Railroad Medicare through the eServices portal. To find the patient’s MBI in the portal, they will have to provide you with their first and last name, date of birth, and their social security number.  Since CMS is taking social security numbers off of Medicare cards, some patient’s may not want to give their social security number out anymore. CMS is providing beneficiaries with an option. If they don’t want to give you their Social Security Number, they can log in into the MyMedicare.gov portal to get their MBIs from there directly. CMS understands that while they’re educating people with Medicare to bring their new Medicare cards when they are getting medical care, they know there may be times when Medicare patients either don’t or can’t.  I think that would include some emergency ambulance transport.

Q. Medicare will not pay for a deceased patient even though a patient is not technically considered deceased until pronounced by a doctor? DOAs are not covered?
A.
Please see slide 29.  There it states that Medicare doesn't pay if the patient dies before the dispatch. After dispatch, before the patient is loaded onboard, before or after arrival at the point-of-pickup, the BLS base rate, but no mileage, may be paid.  If the beneficiary dies after pickup to or upon arrival at the receiving facility, then Medicare may pay for the medically necessary level of service.

This explanation and scenarios of when Medicare does and does not pay is included in the CMS IOM and the Medicare Ambulance Transports MLN product that we have a link to on our resource page along with the link to the IOM.

Addendum:

  • CMS IOM Pub. 100-02, Chapter 10, Section 10.2.6
  • MLN Medicare Ambulance Transports Booklet

Q. Is there any situation when the PCS and an MD order must be obtained?  (RN signs the PCS for transport from hospital to SNF or vice-versa)  Can an MD order in the chart for ambulance transport replace the PCS? 
A.
The order can replace the PCS but must include all of the required documentation (Bene Name, Date of Transport, Medical Problem/Condition that requires transport, health care provider signature with credentials, and date). There is no standard PCS format but the PCS or Order must include all of the above-mentioned requirements.

Q. What is the course number of today’s event?
A.
The course number is RRB1618139, and that can be added to your certificate of attendance for today’s presentation.

Q. I missed the beginning of the webcast. Will the complete presentation be available?
A.
Yes it will. If you are registered for the presentation, the same link that allowed you to join the presentation live today will bring you to the recorded presentation later this afternoon. It usually takes about two hours for that to become available. An email usually goes out to those who have registered to let them know that the recording is available. We will also post a link for the recording to our website within two weeks so that anyone that was not able to attend the presentation today can hear the presentation, see the slides, and access the resources as a recorded presentation.

Q. Is there a way to submit documentation when a claim is filed that will prevent me from receiving and having to respond to an Additional Documentation Request?
A.
The process in which we select claims for review is an automated process. So if there is documentation submitted with a paper claim, or submitted as an attachment to an electronic claim, that does not keep the additional documentation response or ADR letter from being sent out on those claims. We do ask that you respond to the ADR request with the documentation that’s requested or respond with a statement that the run sheet was included with the original claim, if you’re absolutely sure that it was included. It’s safer to respond with the documentation, especially for electronic claims. The other reason we do ask for the documentation is that sometimes documentation may be submitted with a claim, but it wouldn’t be everything that you would send in to support the claim knowing that the claim was going to be reviewed. So there is no way to attach it to the claim coming that would keep us from then sending a letter to request documentation if it was chosen for medical review.

Q. If a beneficiary cannot sign and you have to have another person sign in their absence of being able to sign being possibly the crew members.  Do we need to then send out a form to the beneficiary and if so how many times?
A.
You don't have to obtain the beneficiary/beneficiary representative's signature on the date of transport. You have up to a year (the claims filing period) to obtain the signatures. Medicare also allows you to obtain signature of a representative of the receiving facility, along with a crew member's signature. However, you have to state why the patient could not sign for themselves, and the run sheet has to support the statement.

Addendum: Medicare requires the signature of the beneficiary, or that of his or her representative, for both the purpose of accepting assignment and submitting a claim to Medicare. Medicare does not require that the signature be obtained at the time of transport, but the signature must be obtained prior to submitting the claim to Medicare for payment. See the resources below for the list of individuals who can sign on behalf of the beneficiary, when the beneficiary is physically or mentally incapable of signing the claim.

Signature Resources:

  • CMS IOM Pub. 100-02, Chapter 10, Section 20.1.2
  • 42 CFR 424.36 Signature Requirements

Q. The crew signatures slide states credentials need to be documented. Is that something that is specific to Railroad Medicare?
A.
Palmetto GBA Railroad Medicare is a national Medicare Administrative Contractor. We credential providers across the country, and we also receive claims from beneficiaries from across the country. Therefore, unlike a local Medicare Administrative Contractor, we don’t have on file the documentation or certification of every provider of ambulance services. Our reviewers do try to use the national database for licensure verification, but sometimes the crew are not found in that database. Since we are a national provider, the main way we can verify credentials is by the crew credentials being documented on the run sheet.

Q. Can you use email as a confirmation method of requesting a PCS form?
A.
If the ambulance supplier is unable to obtain the required certification within 21 calendar days following the date of the transport, the ambulance supplier must document its attempts to obtain the requested certification and may then submit the claim. Acceptable documentation that you have made the attempts includes a signed return receipt from the US Postal Service or other similar mail service that demonstrates that the ambulance supplier attempted to obtain the required signature from the beneficiary's attending physician or other authorized individual.

Using email to attempt to obtain the PCS would not be adequate because a signed return receipt would not be available.

If the ambulance supplier is unable to obtain a signed PCS from the patient's attending physician, a signed certification statement may be obtained from one of the following authorized individuals: PA, NP, CNS, RN, Discharge planner who has personal knowledge of the beneficiary's condition at the time the ambulance service is ordered or furnished.

Those variations on who you can receive a signature from are specific to the type of transport. So again, within the resources you will be able to access the slides for today and those slides do indicate when you can use an alternative signature.

Q. Is there an error pg 43?  Non-emergent should be emergent.
A.
On slide 43, the specific requirement description is describing emergency situations. And no PCS would be needed in that case.  However, in Non-Emergency, Non-Repetitive transport when a patient resides at home (or is in a facility) not under the direct care of a physician, then no PCS is required.

Addendum: Slide 43 has been updated to include the Specific Requirements for a non-emergency non-repetitive response. 

Q. Would a repetitive tracheostomy patient be filed as BLS or ALS through Prior Authorization? Suction may be required for some transports of the patient but not all.
A. Railroad Medicare does not participate in the Prior Authorization program.

Q. If the patient is alert & oriented but has a POA, is it a legitimate signature if the POA signs?
A. A POA would be considered an individual who arranges the patient's treatment or manages the patient's affairs, so they could sign on behalf of the beneficiary.

Q. Do you have to have a reason the patient is unable to sign?
A.
Yes.

Q. Are you currently speaking?
A.
Yes.  This presentation is handled through your computer speakers.

Q. I have no sound, is this a problem on your end?
A.
This session runs through your computer speakers. Try refreshing the player console by pressing F5 (Command R on a Mac) on your keyboard.

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