Targeted probe and educate (TPE) round results: Ambulance services - basic life support non-emergent transport and mileage (HCPCS A0428 and A0425)

Top denial / partial denial reasons and high-level results are listed below from each round of ambulance services TPE reviews that have been conducted thus far by First Coast. If you have questions about your individual results, please contact the nurse reviewer assigned to your review for additional information. Additional rounds of review will be utilized when the targeted topic demonstrates a continued need for review with newly identified providers.

Top denial / partial denial reasons

The most common reasons for denial or partial denials are the following:

• Medical necessity – The documentation submitted does not support medical necessity as listed in coverage requirements.
• Insufficient documentation – Insufficient documentation was provided to support the services as billed to Medicare. First Coast Medical Review makes multiple attempts to correct these error types before completion of the review. Below are the following denial reasons for insufficient documentation that we were not able to resolve:
  • The documentation was lacking a valid PCS form or missing credentials to support the PCS was made by a valid provider who was knowledgeable of the beneficiary to support transport.
  • No response to additional documentation requests (ADRs) - Documentation was not submitted to us in a timely manner to support the services billed to Medicare.

Round results