« Back to

Prepayment Review of Emergency BLS Transport HCPCS Code A0429

October 7, 2014
FROM:      Palmetto GBA Medicare
RE:           Prepayment Review of Emergency BLS Transport HCPCS Code A0429

Railroad Medicare’s Medical Review (MR) unit will begin a service-specific review for the HCPCS code A0429, ambulance service, basic life support, emergency transport, (BLS – Emergency).

Our upcoming review is based on recent data from the U.S. Railroad Retirement Board Office of Inspector General (RRB OIG) and the Office of Inspector General U.S. Department of Health and Human Services (HHS OIG), as well as internal data analysis. At the conclusion of this review, we will publish our findings on our website.

Preparing for the Review
As a reminder to our suppliers, regardless of the claims selected for review, coverage guidelines require the following criteria:

‘Emergency response’ service is an immediate response to a 911 call or the equivalent. Some emergency responses are satisfied with a Basic Life Support (BLS) response, while others require a higher level of service. An ‘immediate response’ is one in which the ambulance supplier begins as quickly as possible to take the steps necessary to respond to the call.

The phrase '911 Call or Equivalent' is intended to establish the standard of the nature of the call at the time of dispatch as the determining factor.

However the call is made (e.g., a radio call could be appropriate), it is considered to be of an emergent nature when, based on the information available to the dispatcher at the time of the call, it is reasonable for the dispatcher to issue an emergency dispatch in light of accepted, standard dispatch protocol

An emergency call need not come through 911, even in areas where a 911 call system exists

The determination to respond must be in accord with the local 911 or equivalent service dispatch protocol

There are instances in which the dispatch does not match the level of service required. In these cases, an ALS dispatch occurs, but the beneficiary only requires a BLS intervention. Medicare will only pay for the level of service you provide.

An emergency medical condition is one manifesting itself by acute symptoms of sufficient severity (including severe pain) that the absence of immediate medical attention could reasonably be expected to result in any of the following:Placing the beneficiary's health in serious jeopardy

Serious impairment to bodily functions

Serious dysfunction of any bodily organ or part

Railroad Medicare will presume this definition to be met when documentation clearly substantiates the emergency nature of the ambulance services

The Review Process
If your claim is selected for review, Palmetto GBA will notify you by an Additional Documentation Request (ADR) letter. You will have 30 days to submit all applicable documentation for each claim, along with a copy of the ADR as a coversheet. Records can be submitted via fax, mail or through our Online Provider Services (OPS) tool. See the options below:

Providers with a signed Electronic Data Interchange (EDI) enrollment agreement on file with Palmetto GBA Railroad Medicare may submit their documentation through OPS.

Fax Railroad Medicare ADR responses to (803) 264-8832.
Palmetto GBA Railroad Medicare
Medical Review
P.O. Box 10066 
Augusta, GA 30999

If your documentation is not received by the 45th day, MR will deny your claim. These types of denials may result in future provider-specific complex reviews. 

If your claim is denied for a lack of response or late response to an ADR request, you can request an appeal through the normal appeals process.

Conducting the Review
Our MR department will review your claim and the additional documentation to determine if the services billed were medically reasonable and necessary, based on Medicare’s coverage guidelines. We will also determine liability for denied services. If your claim is denied or paid at a lower level of service, your notification will be displayed on your Remittance Advice (RA).

The overall results from this review will be posted on our website at the end of each quarter and at the end of the review. Railroad Medicare does not post provider-specific results.

For assistance, you can call our Provider Contact Center at 888-355-9165. Representatives are available from 8:30 a.m. to 4:30 p.m. in all time zones with the exception of PT, which receives service from 8 a.m. to 4 p.m. PT.

Guaranteed cash flow during transition.