Postpayment Service-Specific Probe Results for Ambulance Service, Basic Life Support, Non-Emergency Transport for July through September 2021

Palmetto GBA performed service-specific postpayment probe review on HCPCS Code A0428 — Ambulance Services, Basic Life Support, Non-Emergent Transport. This edit was set in Alabama, Georgia and Tennessee. The results for the postpay review, for claims processed July through September, 2021, are presented here. 

Cumulative Results 
A total of 339 claims were reviewed in Georgia and Tennessee combined. (There were no claims reviewed in Alabama for the third quarter of 2021.) Of the claims reviewed, 139 of the claims were either completely or partially denied, resulting in an overall claim denial rate of 41.0 percent. The total dollars reviewed was $71,622.22, of which $29,922.45 was denied, resulting in a charge denial rate of 41.78 percent. Overall, there were 201 auto-denied claims in the region. The top five denial reasons were identified, and the number of occurrences based on dollars denied are:

Alabama Results
No results for Alabama were processed for the July through September 2021 quarter.

Georgia Results
A total of 337 claims were reviewed in Georgia, with 139 of the claims either completely or partially denied. This resulted in a claim denial rate of 41.25 percent. The total dollars reviewed was $71,181.42, of which $29,922.45 was denied, resulting in a charge denial rate of 42.04 percent. The top denial reasons were identified, and the number of occurrences based on dollars denied are:

Tennessee Results
A total of two claims were reviewed in Tennessee, with neither of the claims either completely or partially denied. This resulted in a claim denial rate of 0.0 percent. The total dollars reviewed was $440.80 of which $0.00 was denied, resulting in a charge denial rate of 0.0 percent. There were no denial reasons identified.

Denial Reasons and Prevention Recommendations

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 our website for links to applicable LCDs and NCDs for documentation requirements.
   

ASAVA — Alternative Services Were Available and Should Have Been Utilized

• Prior to billing, ensure that the appropriate HCPCS code is used
• Ensure that the appropriate modifier (GZ or GA) is used for billing claims for non-emergent or non-medically necessary runs when the patient has been informed in advance that the service is expected to be denied by Medicare as not reasonable and necessary
• Include all necessary supporting medical documentation if required for submissions
   

INPSC — Invalid Physician Certification Statement

• Review documentation prior to submission to ensure that the complete signed certificate of medical necessity is included
   

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
   

NORUN — Documentation Received Lacks the Necessary Run Report

• Review documentation prior to submission to ensure that a complete legible run report is included
   

NODOC — Documentation Requested for This Date of Service Was Not Received or Was Incomplete Therefore We Are Unable to Make a Reasonable and Necessary Determination as Defined Under Section 1862(a) (1) (A) of the ACT for the Service Billed and This Service Has Been Denied

• Submit all documentation related to the services billed within 45 days of the date on the ADR letter
• Review documentation prior to submission to ensure that the documentation is complete and that all dates of service requested are included
• Include any additional information pertinent to the date of service requested to support the services billed. For example: original chart notes, diagnostic, radiological or laboratory results.
• For claims denied with a M127 or N29 code listed on the remittance advice, be sure to submit all documentation for all dates of service on that claim with a reopen/redetermination request form by fax to JM Part B (803) 699–2427, JJ Part B (803) 870–0139, or RRB Appeals (803) 462–2218
   

The Next Steps
The service-specific postpayment medical review edits for HCPCS Code A0428 — Ambulance Services, Basic Life Support, Non-Emergent Transport in Alabama, Georgia and Tennessee has been discontinued based on the resumption of the Targeted Probe and Educate (TPE).

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 JJ Redetermination: 1st Level Appeal form (PDF). Questions regarding this medical review can be directed to the Palmetto GBA Provider Contact Center at 877–567–7271.