Instructions for completing the prior authorization request (PAR) coversheet for repetitive scheduled non-emergency ambulance transport
To submit a prior authorization request, complete the prior authorization coversheet.
Failure to populate every field listed below could result in delays in processing your request, a non-affirmed decision, or a determination that the request is incomplete and cannot be processed.
| Field | Description |
|---|---|
| Request type: | Select either Initial, Resubmission or Expedite from the drop-down menu. |
| If, Resubmission selected: | Enter the previous Unique Tracking Number (UTN). |
| Number of trips (Not to Exceed 80 in 60 days): |
Enter the number of one-way trips being requested and that are justified by the attached medical records. Up to 40 roundtrips, or 80 individual transports, within 60 days can be prior authorized. |
| Start of 60-day period | Enter the “start date” of the first requested scheduled repetitive non-emergent transport, as supported by medical records submitted in MM/DD/YYYY format. |
| Procedure Code(s): |
Enter the non-emergency ambulance procedure code (A0426 or A0428). If it is necessary to request prior authorization for both non-emergency ambulance codes for the same beneficiary, print the coversheet and write the second procedure code in the Number of Trips field after you enter the number of trips. |
| Modifier 1 | Enter anticipated origin modifier for the beneficiary. |
| Modifier 2 | Enter anticipated destination modifier for the beneficiary. |
| Supplier name | Enter the ambulance supplier’s full name. |
| Supplier NPI | Enter the ambulance supplier’s 10-digit NPI. |
| Supplier PTAN | Enter the ambulance supplier’s PTAN. |
| Supplier address | Enter ambulance supplier’s full street address. |
| Supplier city, State, Zip | Enter the ambulance supplier’s city, state, and ZIP code. |
| State where ambulance is garaged | Select FL, PR or USVI from the dropdown menu. |
| Beneficiary last name: | Enter the beneficiary’s full last name, to include Jr. or Sr. as appropriate. |
| Beneficiary first name: | Enter the beneficiary’s full first name. |
| Medicare Beneficiary Identifier: | Enter the beneficiary’s MBI. |
| Date of birth (DOB): | Enter the beneficiary’s DOB in MM/DD/YYYY format. |
| Certifying physician name: | Enter the certifying Physician's full name and credentials from the Physician Certification Statement (PCS). |
| Certifying physician NPI: | Enter the certifying Physician's 10-digit NPI. |
| Certifying physician PTAN: | Enter the certifying Physician's PTAN. |
| Certifying physician address: | Enter the certifying Physician's full street address. |
| Certifying physician city, State, Zip: | Enter the certifying Physician's city, state, and ZIP code. |
| Fax number (if decision letter by fax is requested) | If you would like to receive your decision letter by fax, enter your 10-digit fax number (XXX-XXX-XXXX). A copy of the letter will also be mailed to you. |
| Enter the email address of the requestor or contact person | |
| Contact name: | Enter the full name of the individual who can be contacted for questions regarding the prior authorization coversheet and medical records. |
| Contact phone / Ext.: | Enter the 10-digit telephone number (XXX-XXX-XXXX) of the individual who can be contacted for questions regarding the prior authorization coversheet and medical records. |
| Requester name: | Enter the name of the individual submitting the request. When the coversheet is completed, print, and sign the request. |
| Requester phone / Ext.: | Enter the 10-digit telephone number (XXX-XXX-XXXX) of the individual who submitted the request. |
| Requester signature: | Enter the signature of the individual submitting the request. When the coversheet is completed, print, and sign the request. |
| Date: | Provide the date the coversheet was completed in a MM/DD/YYYY format. |