PWW MEDIA
RSNAT Prior-Authorization Tool Kit 
Last Updated: 01/19/22

Prior authorization for repetitive, scheduled, non-emergent ambulance transports (RSNAT) of Medicare beneficiaries is a document-intensive process.  This tool kit is designed to help you document and obtain the information you will need to submit on behalf of your patients.  

This Tool Kit is comprised of three parts:   

1. History and Overview.  This section includes a brief history of the model and a summary of what you need to know about its future.
2. Resources.  This section contains information related to RSNAT-specific resources and useful links.
3. Tools. This publication Kit also provides several customizable sample documents for use in documenting patient need for non-emergent ambulance transport. 

• Tool #1 – Model Repetitive Patient PCS Form.  This Certification of Medical Necessity, for use by your physician partners, is designed to capture all relevant information necessary to determine medical necessity for non-emergent ambulance transports.
• Tool #2 – Sample Call Intake Questionnaire.  This tool is intended to help your call-intake/dispatch personnel ask questions relevant to the type of transport required by the patient condition.
• Tool #3 – Sample Repetitive Patient Assessment Questionnaire.  This tool helps gather information from your patient and their family or caregivers.  
• Tool #4 – Sample Repetitive Patient Clinical Evaluation.  This form is designed to gather information about the patient condition and need for ambulance that may not be documented in a PCR or PCS.
• Tool #5- Model Patient Mobility Report.  This form helps document the functional assessment of the patient.
• Tool #6 - Sample Authorization for Photo/Video.  Authorization to use patient image.
• Tool #7- HIPAA Authorization Form.  Authorization for facilities and physicians to release patient records.