How to Bill Medicaid for Non Emergency Transportation

Non-Emergency Medical Transportation (NEMT) is a Medicaid program ensuring beneficiaries access medically necessary appointments when they lack other transport. This benefit helps individuals attend doctor’s visits, dental appointments, hospital visits, and obtain prescription drugs or medical equipment. NEMT removes transportation barriers, preventing missed appointments and improving health outcomes for Medicaid recipients. Accurate billing practices are important for NEMT providers to receive timely reimbursement and for the program to operate efficiently.

Becoming an Approved NEMT Provider

Provider Enrollment

Becoming an approved NEMT provider for Medicaid involves steps to ensure compliance with federal and state regulations. The initial phase requires completing a provider enrollment application with the state Medicaid agency or its contractor. This process includes submitting organizational information, tax identification numbers, and undergoing background checks for owners and key personnel. The goal is to verify the provider’s legitimacy and capacity to deliver services.

Licensing Requirements

Providers must secure all state and local licenses for operating a transportation business. This may include general business licenses, transportation permits, and vehicle certifications. For example, wheelchair-accessible transport might need additional certifications for equipment and staff. These requirements ensure public safety and operational adherence to standards.

Vehicle Standards

Vehicles used for NEMT services must meet safety and accessibility requirements. This includes regular safety inspections, proper vehicle registration, and adequate insurance. Vehicles may also need features like wheelchair lifts, ramps, or stretcher capabilities, which must be routinely inspected. Comprehensive insurance, including commercial auto liability, is a standard requirement.

Driver Qualifications

Drivers must meet qualification criteria. This includes a valid driver’s license, thorough background checks, and a clean driving record. Many states require specialized training, such as first aid, CPR, defensive driving, and patient assistance techniques. These programs ensure beneficiary safety and well-being during transport.

Compliance Training

NEMT providers and staff must complete compliance training, especially concerning the Health Insurance Portability and Accountability Act (HIPAA) and fraud, waste, and abuse (FWA) prevention. HIPAA training protects patient health information. FWA training educates providers on preventing fraudulent billing, maintaining program integrity, and avoiding penalties.

Preparing NEMT Claim Information

Eligibility Verification

Accurate preparation of NEMT claim information begins before the service is rendered. Verifying a Medicaid beneficiary’s eligibility is a step for each trip. This involves checking the beneficiary’s Medicaid identification number through a state’s online portal or automated system to confirm active coverage and NEMT benefit eligibility for the date of service. Ensuring eligibility upfront prevents claim denials.

Prior Authorization

Prior authorization is often required for NEMT services, especially for certain transport types or beneficiaries with specific medical conditions. Providers must obtain this authorization from the state Medicaid agency or its broker before the trip. The request includes patient demographics, medical necessity details, appointment date/time, and pick-up/drop-off locations. Once approved, the unique authorization number must be recorded as it is a mandatory claim field.

Trip Details

Detailed trip information is important for accurate claim submission. This includes the date of service, pick-up address, and drop-off address for each journey leg. Recording mileage traveled, often using odometer readings or GPS, is a common reimbursement requirement. Documenting pick-up and drop-off times helps justify service duration and cost.

Service Codes

Selecting correct service codes is important for NEMT claims. Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) codes describe the transportation type. Examples include codes for ambulance services (e.g., A0428), wheelchair van transport (e.g., A0130), stretcher van services, and mileage reimbursement (e.g., A0021). Providers must ensure the chosen code accurately reflects the service rendered.

Diagnosis Codes

Diagnosis codes from the International Classification of Diseases (ICD) may be required to justify medical necessity. While NEMT is not a direct medical procedure, the patient’s underlying condition necessitating transport may need to be linked. This shows why the beneficiary cannot use other transport and needs assistance to reach their appointment.

Provider and Driver Information

Provider and driver information must be associated with each claim. This includes the NEMT provider’s National Provider Identifier (NPI) and state-specific identification numbers. Details about the driver, such as name or employee ID, may be required for audits and to ensure compliance. This information helps trace accountability and verifies authorized service.

Supporting Documentation

Maintaining comprehensive supporting documentation for each NEMT trip is important. This may include detailed trip logs, patient signatures, and copies of physician orders or medical necessity forms. These records support the claim and are important during audits or claim denials. Proper record-keeping ensures transparency and substantiates billed services.

Submitting NEMT Claims

Submission Methods

Once NEMT claim information is prepared, the next step is submission to the appropriate Medicaid entity. Methods include Electronic Data Interchange (EDI), online provider portals, or paper claims. Each method has protocols for successful transmission and processing.

Electronic Data Interchange (EDI)

EDI is a common method for submitting claims efficiently. Providers connect with a clearinghouse, an intermediary between the provider and state Medicaid agency, or transmit directly. This involves converting data into a standardized electronic format, like the 837P transaction set, and securely transmitting it. Setting up EDI requires software or services.

Online Provider Portals

Many state Medicaid programs offer secure online provider portals for direct claim submission. These platforms allow providers to enter or upload electronic claim files. Using a portal provides immediate submission confirmation and can display real-time claim status. Providers must register for an account and adhere to the portal’s data entry requirements.

Paper Claims

For paper claims, the CMS-1500 form is standard for professional services, including NEMT. After completing fields, the claim is mailed to a designated address. Use the most current CMS-1500 form and ensure entries are legible and accurate to avoid processing delays or rejections.

Claim Deadlines

Claim submission deadlines are important. Medicaid programs enforce time limits for filing, which vary by state, from 90 days to one year from the date of service. Submitting claims past deadlines can result in payment denial, so track submission dates diligently. Providers receive confirmation of claim submission, serving as proof of timely filing.

Managing NEMT Claim Outcomes

Claim Processing

After an NEMT claim is submitted, understanding processing and outcomes is important for revenue cycle management. Medicaid claims undergo an adjudication process that can take several weeks. During this period, submitted information is reviewed against eligibility, authorization, and coding rules.

Remittance Advice (RA) and Explanation of Benefits (EOB)

Providers receive formal communication on claim status, usually through a Remittance Advice (RA) or Explanation of Benefits (EOB). These documents detail approved, denied, or partially paid claims. The RA/EOB provides codes and explanations for adjustments or denials.

Reasons for Denial

Common reasons for NEMT claim denials include missing or expired prior authorization, incorrect service (CPT/HCPCS) or diagnosis (ICD) codes, or duplicate submissions. Other denials stem from patient eligibility issues or discrepancies in mileage or trip times.

Appeals Process

If a claim is denied, providers have the right to appeal. The appeal process involves submitting a formal request for review, often within 30 to 90 days from the denial date. The appeal requires additional documentation or clarification to address the original denial reason. Understanding appeal procedures and deadlines is important for overturning denials.

Payment Disbursement

Once claims are approved, payments are disbursed to providers. Many Medicaid programs use Electronic Funds Transfer (EFT) for direct deposit, an efficient method. Payments may also be issued via paper checks. Monitoring payment processing and reconciling funds with claims and RAs is important for accurate financial records.