CurrentAspirus ArisePolicy N/A

Non-emergent fixed wing air ambulance prior authorization request form

Form and process for requesting prior authorization for non-emergent fixed-wing air ambulance transport for Aspirus Arise members; applies to ordering practitioners, servicing and receiving providers, and administrative staff submitting requests. Emergent transports do not require prior authorization.

Policy Summary

PayerAspirus Arise

PolicyNon-emergent fixed wing air ambulance prior authorization request form

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionComplete and submit the prior authorization request form with required clinical documentation via fax to 715.787.7316.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

10 business daysstandard decision timeframe for Medicare and Medical Assistance

72 hoursexpedited decision timeframe for Medicare and Medical Assistance

715.787.7316fax number to submit form and clinical documentation

A0430, A0435listed ambulance CPT/HCPCS codes on form

No prior authorization required

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Medical Necessity and Coverage Criteria

Medical necessity and documentation criteria

Medical necessity must be documented on the form and supported by clinical notes; select appropriate clinical reason(s) and required monitoring and explain facility differences.

ALL of the following

Clinical reason (select ONE or more)
- Burn
- Cardiac
- Neonatal
- Neurological
- Psychiatric inpatient
- Respiratory
- Trauma
- Other (specify)
Monitoring needs (select ONE or more)
- Oxygen (portable O2 does not apply)
- Comatose
- Cardiac monitoring
- Airway management
- Life support
- Suction
- Behavioral monitoring
Explain the specialty care the accepting/receiving facility provides that cannot be provided at the current facility (required)
Attach clinical notes supporting any of the above; incomplete submissions can delay decision time (required)

Air Ambulance Codes and Billing Rules

Air ambulance HCPCSHCPCS

A0430	Fixed wing air ambulance, transport, single patient, per transport
A0435	Fixed wing air ambulance, transport, multi-patient or other (as listed)

Expedited review limitation (billing/retrospective)

Billing/retrospective authorizationsBilling and retrospective authorizations are not eligible for expedited review.

ApplicabilityExpedited review applies only to urgent requests where waiting could jeopardize health, life, or function; it does NOT apply to billing or retrospective requests.

Action for providersDo not submit billing-only or retrospective authorization requests as expedited; these will be processed under standard timeframes.

Prior Authorization Submission & Request Processing

Prior Authorization

Submission Instructions — Prior Authorization Required

Complete and submit the Non-Emergent Fixed Wing Air Ambulance Prior Authorization Request Form and include all required clinical documentation to support medical necessity. Fax the completed form and relevant clinical documentation to: 715.787.7316. No prior authorization is required for emergent transportation. Incomplete, illegible, or inaccurate forms will be returned to the sender; failure to provide required documentation may result in denial or delay of the request.

Complete the entire prior authorization request form
Include supporting clinical notes and documentation with the submission
Fax to 715.787.7316
Emergent transports: no prior authorization required

Prior Authorization

Request Type and Timeframes

Please select whether this is a STANDARD REQUEST or an EXPEDITED REQUEST on the form before submission. Choose EXPEDITED only when waiting for the standard review timeframe could jeopardize the member's health, life, or ability to regain function. Billing and retrospective authorizations are not eligible for expedited review.

Important Definitions

Emergent transportation exception

Emergent transportation ruleNo prior authorization is required for emergent transportation.

Form instructions contextThe prior authorization form and supporting clinical documentation are required for non-emergent transports only; emergent transports are exempt.

Submission noteFax number for submitting non-emergent requests and documentation: 715.787.7316.

Expedited request definition and requirements

DefinitionAn expedited (urgent) request is an urgent/emergent review requested when waiting for the standard review timeframe could potentially jeopardize the member's health, life, or ability to regain function.

When to requestRequest expedited only for clinical urgency unrelated to scheduling; include the clinical reason for urgency on the form.