What Is a 3200 Form for Ambulance Services?

While sometimes referred to by informal names like a “3200 form” or a “Certificate of Medical Necessity” (CMN), the official document required within the Medicare system to justify non-emergency ambulance transportation is the Physician Certification Statement (PCS). Medicare does not issue a single, official form; instead, providers use documents that contain all the required information. This statement is a signed declaration from a healthcare professional that a patient’s medical condition makes it unsafe to use any other form of transport, such as a car or wheelchair van.

The document is a prerequisite for Medicare to consider payment for scheduled, non-urgent ambulance trips. It establishes a clear medical reason for the service, linking the patient’s health status directly to the necessity of ambulance-level care during transit. Without this certification, the ambulance provider cannot submit a claim to Medicare for these transports.

Establishing Medical Necessity

The principle for approving non-emergency ambulance transport is medical necessity, which is established when a patient’s condition is such that using any other transportation method would endanger their health. This is a strict standard that goes beyond convenience, and the justification must be based on the patient’s state at the time of the transport.

A patient is considered “bed-confined” if they meet three criteria: they are unable to get up from bed without assistance, they are unable to ambulate, and they are unable to sit in a chair or wheelchair. All three conditions must be met. This status is a strong indicator of medical necessity, but it is not the only qualifying circumstance.

A patient may also qualify if they require medical monitoring or treatment during the trip that can only be furnished by trained ambulance personnel. This could include needing cardiac monitoring, the administration of IV medications, or oxygen that the patient cannot self-administer. The required service during transport must be something that could not be provided in a private vehicle.

Required Information and Form Completion

A blank Physician Certification Statement is typically provided by the ambulance company scheduling the transport. Any version used must contain specific information to be considered valid by Medicare. The document must capture all the data necessary for a reviewer to understand why the ambulance service was the only safe option.

The form requires the patient’s full name, date of birth, and their Medicare Beneficiary Identification (MBI) number. It also details the date of the transport, the pickup location, and the destination. The medical information section requires a detailed narrative from the certifying healthcare professional describing the patient’s condition and explicitly stating why other means of transport are contraindicated. Vague statements like “patient is weak” are insufficient.

The requirements for who can sign the PCS and when it must be obtained depend on the nature of the transport. For repetitive, scheduled transports, the statement must be signed by the patient’s attending physician before the first trip and can be valid for up to 60 days.

For non-emergency transports that are unscheduled or non-repetitive, the ambulance provider must obtain the PCS from the attending physician within 48 hours after the transport. If the physician’s signature cannot be obtained in that timeframe, the certification can be signed by a registered nurse or physician assistant with personal knowledge of the patient’s condition.

The Submission and Review Process

The patient or their representative is responsible for ensuring the signed form is given to the ambulance provider. The provider must have the completed certification in their possession before submitting a claim to Medicare.

The ambulance supplier submits the claim package, including the PCS, to the appropriate Medicare Administrative Contractor (MAC). The MAC is a private health insurer that has been awarded a geographic jurisdiction to process Medicare claims.

Upon receipt, the MAC reviewer assesses the information on the PCS to determine if the justification for the ambulance transport aligns with Medicare’s coverage guidelines. They will verify that the patient’s condition, as described, meets the criteria for medical necessity. The outcome of this review can be an approval, resulting in payment to the ambulance provider, or a denial if the documentation is insufficient.