Inter-Facility Transport

(The forms on this page require Adobe Acrobat Viewer. You can download it HERE.)

Medicaid Patients

Patients who have only Medicaid Insurance are required to have pre-authorization via the "Medicaid Report" form. Pre-authorization is required for non-emergency transports occurring Monday through Friday from 07:00 AM to 5:00 PM, excluding holidays. Transports occurring after business hours or on holidays or weekends must have "post-approval" performed. In either case, completion of the Medicaid Report form is required.

Your health care facility should have Medicaid Report forms on hand. The form must be filled out and faxed to the Medicaid Office at 727-588-6865, prior to setting up the ambulance transport for your patient. The Medicaid Office will fax the form back to you as either approved or denied. If the transport has been approved, contact the Sunstar Communication Center at 727-530-1234, to set up the transport. The transport coordinator in the communication center will ask if the patient has Medicaid and will request the Medicaid Report form with authorized pre-approval to be faxed to him/her for verification (727-582-2416).

If you cannot locate a form at your facility, one can be downloaded here or faxed to your location to be completed and faxed prior to transport. On some occasions when the transport is more time critical, the transport coordinator may obtain the needed information over the phone, complete and fax the form for you.

If the Medicaid Report form returns with a denial by the Medicaid Office, you will need to determine if another form of transport is an option for the person. You may opt to utilize an ambulance with the understanding that your facility or the patient may be responsible for the ambulance bill. Failure to attempt pre-authorization will disallow any appeal for non-reimbursement after the transport.

The completed form should be provided to the ambulance personnel when they arrive to transport the patient for business and non-business hour transports.

Note: Section 401.252, Florida Statutes requires anyone who needs or is likely to need medical attention during transport, must be transported in a permitted ambulance.

Medicare Patients

Patients who have Medicare are required by Federal regulations to have a "Physician Certification Statement" (PCS) form (previously referred to as a CMN form) completed with a physician’s signature at the time of transport. This is regardless of time of day or day of week. The PCS form is not required for emergency responses and transports. The PCS form is used to justify the medical need for ambulance transport in order for Medicare to consider payment.

The form should be completed and provided at the time of transport. This allows the form to be processed by Sunstar in the timeframe Medicare allows. The completed form should be provided to the ambulance personnel when they arrive to transport the patient.

Obtaining a physician signature has already proven to be the biggest challenge in completing the PCS form. It is recommended that you obtain a physician signature on the form when the physician is writing orders for transfer or discharge. If the transport occurs when a physician is not present, a Registered Nurse can sign the form in consultation with, and on the verbal order of the attending physician. The physician is then required to countersign the certification before the bill can be submitted. In these cases, the form signed by the Nurse is given to the ambulance personnel. Sunstar can then fax the form after the transport to the physician’s office for a counter signature. (Therefore, it is important to provide the Physician’s office fax number on the form). If you cannot locate a PCS form, one can be faxed to you by contacting the Sunstar Communication Center at 727-530-1234.

Skilled Nursing Facility Patients

Non-emergency ambulance transportation for a Medicare patient residing in a skilled nursing facility (SNF) requires a Prospective Payment System (PPS) form. When a skilled nursing facility calls for a non-emergency transport, Sunstar's call-taker asks the caller specific questions regarding the patient's insurance coverage. If the patient is covered by Medicare the caller is informed that a PPS form is required in addition to the PCS form. The SNF staff is responsible for completing the PPS form and providing it to the paramedic when the patient is picked up from the facility. The PPS form is required by the County and helps them to determine which payer source to bill (Medicare or the SNF).

The Balanced Budget Act of 1997 requires the SNF to pay for all ambulance transports that are part of a residents "plan of care". For example, a patient is being treated in a nursing facility after fracturing a hip and subsequent hip surgery. The patient cannot walk or sit, but has an appointment with their orthopedic doctor. The patient can be safely transported only by ambulance, and since this transport falls under their care plan, the SNF is responsible for the ambulance bill. An example of when Medicare would be billed is if this same patient developed a severe infection at their surgery site. This would be an unexpected occurrence, i.e., not in their plan of care. The patient's condition would require further evaluation and treatment not available at the skilled nursing facility. Therefore, the patient would be transported by ambulance to the emergency room and this transport will be billed to Medicare. The PPS form was designed by the County to assist them in billing skilled nursing patient transports appropriately.