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CGS PAR 679: RSNAT Ambulance Prior Authorization

Ambulance suppliers in Kentucky and Ohio use this CGS form to request Medicare prior authorization for repetitive, scheduled non-emergent ambulance transport, such as trips for dialysis or wound care. One request covers up to 40 round trips in a 60-day period. Physicians meet it because the request rests on their signed Physician Certification Statement (PCS) and the patient's medical records.

Who completes it

The ambulance supplier completes the form, including HCPCS codes, the start of the 60-day period and the number of transports, and names the certifying physician with NPI, PTAN and address. The physician's part is the signed, dated PCS and the supporting records that CGS checks against eight questions.

Submitting and payment

How to submit it
The supplier submits through myCGS (preferred), esMD, the Kentucky or Ohio fax line, or by mail. Suppliers and patients receive a decision letter within 7 calendar days.
Who pays
Claims carrying the UTN of an affirmed decision will pay, while claims tied to a non-affirmed UTN will deny, with appeal rights.

Good to know

  • Transport counts as repetitive with 3 or more round trips in 10 days, or at least 1 round trip per week for 3 weeks. It covers HCPCS A0426 (ALS1) and A0428 (BLS) transports.
  • If the supplier has not requested prior authorization before the 4th round trip, all related claims become subject to prepayment medical review.
  • CGS checks that the PCS signature carries credentials meeting CMS signature rules, is dated rather than prefilled, and predates the start of the 60-day period on the request.
  • The certifying physician named on the request must match the PCS, which must also state why other means of transport are contraindicated and give the origin and destination.

Get the official form

Download the current version from the source each time; forms change without notice.

Prior Authorization: Repetitive, Scheduled Non-Emergent Ambulance Transport (RSNAT)

Official pagePDF

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

What does CGS check on the physician certification statement for RSNAT?

Whether a PCS is present, signed by a physician with credentials meeting CMS signature rules, dated and not prefilled, signed before the start of the 60-day period, and from the same physician named on the request. It must also explain why other transport is contraindicated and give the origin and destination.

How many trips does one RSNAT prior authorization cover?

Up to 40 round trips in a 60-day period per request. On the form a round trip counts as 2 transports, so the number of transports requested is twice the round trips. Up to two HCPCS codes with modifiers can be listed for one beneficiary.

Is RSNAT prior authorization nationwide?

Yes. CMS has required repetitive, scheduled non-emergent ambulance prior authorization nationwide since 2022, and each Medicare Administrative Contractor publishes its own request form. PAR 679 is CGS's form for Kentucky and Ohio, originated February 25, 2022, and revised October 17, 2024.