Overview of the RSNAT Prior Authorization Model
The RSNAT Prior Authorization Model was introduced by CMS to address concerns about potential overutilization of repetitive, scheduled non-emergent ambulance transport services. The model aims to ensure that these services are medically necessary and meet Medicare requirements before they are provided. By requiring prior authorization, CMS seeks to reduce unnecessary expenditures and safeguard the integrity of the Medicare program, without negatively affecting beneficiaries’ access to quality ambulance transport services.
The model operates by requiring ambulance service providers in participating states to obtain prior authorization for repetitive, scheduled non-emergent ambulance transports before submitting claims for payment. This process involves submitting documentation to Medicare Administrative Contractors (MACs) demonstrating that the transport meets specific medical necessity criteria.
Nationwide Expansion of the RSNAT Model
Recognizing the success of the initial model in reducing costs and maintaining quality of care, CMS expanded the RSNAT Prior Authorization Model nationwide. This expansion was based on positive evaluations and certifications confirming the model’s effectiveness.
The nationwide rollout occurred in phases, with different implementation dates for various states and territories:
- December 1, 2021: Arkansas, Colorado, Louisiana, Mississippi, New Mexico, Oklahoma, and Texas.
- February 1, 2022: Alabama, American Samoa, California, Georgia, Guam, Hawaii, Nevada, Northern Mariana Islands, and Tennessee.
- April 1, 2022: Florida, Illinois, Iowa, Kansas, Minnesota, Missouri, Nebraska, Puerto Rico, Wisconsin, and U.S. Virgin Islands.
- June 1, 2022: Connecticut, Indiana, Maine, Massachusetts, Michigan, New Hampshire, New York, Rhode Island, and Vermont.
- August 1, 2022: Alaska, Arizona, Idaho, Kentucky, Montana, North Dakota, Ohio, Oregon, South Dakota, Utah, Washington, and Wyoming, along with nationwide coverage for Railroad Retirement Board beneficiaries.
This phased approach ensured a smooth transition and allowed providers across the United States to adapt to the new prior authorization requirements for ambulance transport services.
Key Updates and Changes to the RSNAT Model
Throughout its implementation, CMS has made several important updates to the RSNAT Prior Authorization Model to refine its operations and address stakeholder feedback. Key updates include:
Changes to Review Timeframe (Effective January 9, 2025):
- The standard prior authorization review timeframe has been adjusted from 10 business days to 7 calendar days, streamlining the process for providers seeking approvals for ambulance transport services.
- The option for expedited prior authorization review has been removed, as the model is designed for non-emergent, scheduled services that do not typically require urgent review. This change aims to focus resources on standard reviews and maintain efficiency.
Resumption of Model Activities (August 3, 2020):
- After a temporary pause due to the COVID-19 public health emergency, CMS resumed full operations of the RSNAT Prior Authorization Model on August 3, 2020. This included reinstating prepayment review for ambulance transport services if prior authorization was not obtained after the fourth round trip in a 30-day period.
- Postpayment reviews were also conducted for claims submitted and paid during the pause without prior authorization, ensuring program integrity was maintained retroactively.
Expansion to Additional States (January 1, 2016):
- Prior to the nationwide expansion, the model was expanded to include Delaware, the District of Columbia, Maryland, North Carolina, Virginia, and West Virginia, effective January 1, 2016. This expansion marked an early step towards broader implementation and demonstrated the model’s scalability.
Initial Implementation (December 15, 2014):
- The RSNAT Prior Authorization Model was initially launched in South Carolina, New Jersey, and Pennsylvania on December 15, 2014. This initial phase served as a pilot program to test the feasibility and effectiveness of prior authorization in managing repetitive, scheduled non-emergent ambulance transport services.
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Resources and Further Information
CMS provides numerous resources to help ambulance service providers and other stakeholders understand and comply with the RSNAT Prior Authorization Model. These resources include:
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Statistics Documents: CMS regularly releases updated statistics on the RSNAT Prior Authorization Model, providing transparency and insights into the model’s performance. These reports detail the impact of prior authorization on service utilization and Medicare spending.
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Open Door Forums: CMS hosted Special Open Door Forum calls to discuss the nationwide expansion and other aspects of the RSNAT model. These forums provided opportunities for stakeholders to ask questions and receive clarification directly from CMS officials. Presentation materials from these forums are available online.
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Operational Guide and FAQs: Comprehensive operational guides and frequently asked questions (FAQs) documents are available to assist providers in navigating the prior authorization process. These resources offer detailed instructions and answers to common questions, ensuring providers have the information they need to comply with the model requirements.
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Medicare Administrative Contractors (MACs): Providers are encouraged to engage with their respective MACs for education and support related to the RSNAT Prior Authorization Model. MACs serve as a primary point of contact for providers seeking guidance on specific implementation and operational details within their jurisdictions.
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Conclusion
The CMS RSNAT Prior Authorization Model represents a significant effort to manage the utilization of ambulance transport services and ensure appropriate Medicare spending. Through nationwide expansion and ongoing updates, CMS aims to strike a balance between program integrity and beneficiary access to necessary healthcare transportation. Ambulance service providers must stay informed about the latest updates and utilize available resources to effectively navigate the prior authorization process and continue providing essential ambulance transport services to Medicare beneficiaries. For the most current information and detailed guidance, stakeholders should regularly consult the official CMS website and resources provided by their MACs.
