Medicare Denials and Appeals

Unfortunately, not all ambulance transports are covered by Medicare. Under Medicare’s strict guidelines, certain criteria must be met in order for the transport to be deemed “medically necessary”.

Medicare states “Medical necessity is established when the patient’s condition is such, that use of any other method of transportation besides ambulance is contraindicated and may further endanger the individual’s health or life, whether or not alternative transportation is available at the time”

 

Right to Appeal Decision

If you do not agree with Medicare’s decision, an appeal may be filed within 120 days from the denial date. As a courtesy and if deemed appropriate; Alert Ambulance Inc, can help assist you in the appeal process.

This process is called Reconsideration. In order to effectively file for reconsideration, supporting materials such as doctor’s letters and medical records stating why the patient’s condition met need for ambulance transport should be included.

There are 3 different denial codes; along with a brief explanation, that may be appealed if deemed necessary and accompanied by proper documentation, they are as follows:

PR-B8: (Claims/ services not covered or reduced because alternative services should have been utilized) If any other means of transportation could have been used without endangering the patient’s health, payment cannot be allowed for transport. Other forms of transportation include wheelchair van, taxi, bus or private and/or nursing facility owned vehicle. This holds true regardless of, but not limited to time of transport, patient’s lack of appropriate attire, weather conditions or availability of transportation.

PR-50: (Transport not deemed medically necessary) (see PR-B8)

PR-117: (Not transported to the closest appropriate facility) Medicare will not cover transports over 50 miles. Documentation is needed as to why the patient could not have been treated or transported to a closer available facility.

If Appeal is Denied

If the Redetermination appeal is denied, the next level of appeal is called Reconsideration, where the appeal is sent to an independent contracting agency devised of nurses and doctors who review the claim for medical need.

If the Reconsideration is denied, the next and usually final level of appeal would be to an Administrative Law Judge, who will hold a hearing to determine whether the claim falls within Federal Regulation Guidelines.

It usually takes approximately 90 days for a decision to be made each appeal level.

Due to the complicated appeal process, Alert Ambulance Inc. has highly trained staff members to either appeal a claim on behalf of a patient or to assist in the process. However, your assistance is also needed, the more information we can receive the more successful the appeal process.

When a claim has been denied, Alert Ambulance Inc. will automatically send an invoice to the patient. It will state the reason for the denial. It is very important that you contact us immediately upon receiving this statement, in order to assist in your appeal.

Our contact number is 1-888-665-2475 ext 2.

Other Resources

Another very helpful resource for help with the appeals process is The Medicare Advocacy Center. Each year, the Center represents thousands of individuals in appeals of Medicare denials. The Center is staffed by attorneys, nurses, legal assistants, and information management specialists.  A complete explanation of the organization's publications, products, and services are available on their website www.medicareadvocacy.org