NON-EMERGENCY MEDICAL TRANSPORTATION (NEMT) BROKERAGE . - Oregon
NON-EMERGENCY MEDICAL TRANSPORTATION(NEMT)BROKERAGE OPERATIONS MANUALDivision of Medical Assistance ProgramsJuly 2013
ContentsDEFINITION OF TERMS. 1PRIMARY OPERATING COMPONENTS . 3Administrative Responsibilities. 3Customer Service Representative (CSR) Responsibilities . 3Brokerage or Scheduling Department Responsibilities . 4Billing/Data Entry Department Responsibilities . 4Quality Assurance Personnel Responsibilities . 4SERVICE AREA . 5CONFIDENTIALITY . 5Sharing or Inquiries about a client . 5CALL TAKING . 6Abusive Callers . 6ELIGIBILITY VERIFICATION . 6MEMBER ENROLLMENT VERIFICATION . 7AUTHORIZATION OF TRANSPORT . 7Screening Procedure . 8Closest Provider of Type. 10Exceptions: . 10TYPES OF TRANSPORTATION . 11Public Transit . 11Sedan . 11Wheelchair Transport . 12Ambulance . 12Stretcher Car . 12Secure Transport . 12Volunteer Transport . 13Other Types of Transport . 13Selection of Transportation Provider . 14Estimate of Ride Cost . 14Provider Preference . 14i
Advance or Prior Authorization for Unknown Date . 14Children in the Care of the Department of Human Services (DHS) . 15Hospital Patient Transport . 15Same-Day Request . 16DOCUMENTATION AND DATA . 16Computer Failure . 17Computer Data Input . 17TRIP VERIFICATION . 17CONTINGENCY PLANS TO ASSURE LIFE-SUSTAINING RIDES. 18EXTRAORDINARY TRANSPORTS . 18Authorization for non-emergency ambulance transports . 18Out-of-Area Trips . 20Special Considerations . 20Local Ordinances . 20Out-of-Area Stretcher Car Rides . 20Transport not Available . 20DENIAL OF SERVICE . 21COMPLAINTS/RIDE DENIALS . 22Review and Contested Case Hearing Process . 22Local Process . 22State-Level Process . 22CLIENT CONVENIENCE . 23ATTENDANTS . 23Travel with a minor . 23Paid Provider Attendant . 24NO-SHOW . 24AFTER-HOUR TRANSPORTATION . 24BUS PASSES AND TICKETS . 25CHILD RESTRAINTS . 27EMERGENCY RESPONSE . 27TRANSPORTS TO A PHARMACY . 28ii
CLIENT ABUSE OF TRANSPORTATION SERVICES . 28TEST OF REASONABLENESS . 29COMMUNICATION WITH BRANCH OFFICES . 30General. 30Services for Children . 30CLIENT and ATTENDANTREIMBURSED TRAVEL . 30Guidelines . 30Mileage Reimbursement . 31Meals . 32Lodging. 33Extended Duration Stays . 34Attendant . 35Travel Advance . 36PROVIDER PROCEDURES . 37Provision of Service . 37Transportation Provider Responsibilities . 37Maintenance of Service . 37Transportation Provider Documentation. 38Transportation Provider Billing Procedures . 38No-Show Policy . 38Donations for Rides . 38Shared Rides . 38APPENDIX . 1A.Client Reports (CSI) - The Brokerage Procedures . 1I. DEFINITIONS of . 1II. PROCEDURE FOR HANDLING CUSTOMER SERVICE INFORMATION . 1B.HANDLING COMPLAINTS OR NEGATIVE BEHAVIOR . 3C. LETTERS . 5Denial Example Letter . 5Doctor Example Letter. 7No-show Example Letter . 8HIPAA Example Letter . 9iii
D.COVERED TRANSPORTS . 10Covered Transports . 10Not Covered Transports and Related Services. 12E. Fee Schedule – Client/Attendant Reimbursed Travel . 16F. Resources . 17OHA Resources . 17Other Resources . 17Air ambulance companies enrolled with DMAP . 18G. Forms . 19DMAP 405T Medical Transportation Order. 19iv
DEFINITION OF TERMSAdvocate - An individual or other entity requesting services on behalf of the client.After Hours - A trip provided when the brokerage is not open. Clients may call thetransportation provider directly for a trip when brokerage staff is not available to authorize aride.Attendant - A client escort/assistant provided by the client in those instances where anattendant is necessary.Broker - The local governmental agency that holds the Medicaid contract to provide nonemergency medical transportation (NEMT) to Medicaid eligible clients within a designatedservice area.Brokerage - The service contracted to provide screening and authorization for NEMT servicefor Medicaid clients. The brokerage also subcontracts with transportation providers whoprovide service for Medicaid clients.Case Manager (Case worker) - Authorized DHS branch staff that manages the client’s overall benefits.Client Preference-Client desire to ride with a particular provider or use a particular mode oftransportation for reasons that are not based on medical needCovered Medical Service - A medical service that is part of the client’s Oregon Health Plan(OHP) benefit packageCustomer Service Incident Report (CSI) - Documentation of complaints, concerns, orcompliments regarding providers or the brokerage staff.Customer Service Representative (CSR) - Staff member who handles all aspects of telephonerequests for rides or authorization for reimbursement of transportation expenses and entersinformation into the database. Eligible Client -Division of Medical Assistance Programs(DMAP) client who is eligible for medically necessary and appropriate transportation to OregonHealth Plan-covered services.Lowest Cost - The lowest cost per trip that one transportation provider charges as opposed toanother of comparable level of service, and the least costly, most appropriate mode oftransportation that is appropriate for the client based on the medical needs.Quality Assurance Personnel - DMAP or brokerage personnel responsible for assuring thequality and safety of rides for clients.Non-Emergent Transportation Services Brokerage Manual1
Routine Trips - Group or individual trips taken more than once per month on the same day ofthe week by the same group or individual to the same destination. These are generallyscheduled monthly.Shared Ride Service – Multiple-client ride service, may include non-Medicaid passengers (forexample, a passenger van providing service to Medicaid clients at the same time as clients withother social services)Third Party Providers - Other medical insurance such as Veterans Administration Services orMedicare, or charity care a client receives from a specific provider at a savings to Medicaid.Transportation Provider - Any public, private or private non-profit organization or individualwho has been designated by the brokerage to receive reimbursement for medical transportationat a negotiated rate, for medical transportation provided, as authorized, by the brokerage.Transportation may include, but is not limited to sedan, wheelchair van, public transit, stretchercar, secured transport, and volunteers driving their own vehicles.Transportation Type - The mode of transportation used to provide transportation services toclients. Types may include, but are not limited to, public or private fixed-route service,individual ride service, or shared ride service.Unscheduled Trip - A demand-response trip that is immediate in nature. These trips may occuroutside of normal business hours.Urgent Transport - Transportation provided on an urgent or same day basis when the clientneeds immediate treatment but the medical condition is not emergent (see Emergency Servicesdefinition in the DMAP General Rules, OAR410-120-0000).2OHA – Division of Medical Assistance Programs
PRIMARY OPERATING COMPONENTSAdministrative ResponsibilitiesThe responsibilities of the brokerage’s administrative staff include the following: Have a thorough understanding and knowledge of Medicaid rules, procedures, andpolicies. Assure quality telephone call response service and authorization service to include, butnot be limited to, verifying that no conflict of interest exists in the assignment of rides. Assure protection of client information. Provide appropriate and timely training and program information to staff. Coordinate with brokerage staff to improve and maintain service. Assist in the development or modification of local policies and procedures. Respond to client concerns, grievances, or appeals. Verify provider billing and prepare required reports and documents. Respond to provider concerns.Customer Service Representative (CSR) ResponsibilitiesThe responsibilities of the CSR include the following: Receive client requests for transportation. Receive client requests for authorization to incur reimbursable medical transportationrelated expenses, such as mileage, meals, and lodging to access covered medicalservices. Assure protection of client information. Verify Medicaid eligibility and covered services. Assess need for particular type of transportation. Determine no other transportation or funding source available. Maintain complete and appropriate documentation of ride requests and authorizations,problems that occur, and other information as needed.Non-Emergent Transportation Services Brokerage Manual3
Have a thorough knowledge and understanding of Medicaid transportation rules,procedures, and policies.Brokerage or Scheduling Department ResponsibilitiesThe responsibilities of the brokerage or Scheduling Department include the following: Select least costly, most appropriate transportation. Assess mileage for Medicaid trips and assign estimated costs based on providercontracts. Maintain complete and appropriate documentation of provider problems or concerns. Arrange and examine provider schedules to assure timely pick up of clientele.Billing/Data Entry Department ResponsibilitiesThe responsibilities of the Billing/Data Entry Department include the following: Verify provider billing and prepare required reports and documents. Bus pass and ticket distribution and inventory. Data entry of all faxed ride requests. Completion of mandatory, daily computer hardware and software functions. Conduct contracted provider billing audits. Completion of spreadsheets, reports, and queries for administrative use. Provider instruction in computer use and billing functions.Quality Assurance Personnel ResponsibilitiesThe responsibilities of the quality assurance personnel include: Investigate and document complaints. Report back to complainant and to brokerage advisory committee. Provide outreach and training as required to clients, advocates and others who mayinterface with the brokerage.4OHA – Division of Medical Assistance Programs
SERVICE AREAThe brokerage is responsible for providing NEMT to Medicaid clients who reside in thebrokerage SERVICE AREA who are receiving OHP-covered services. Brokerages maycoordinate to provide rides to clients who live in the service area of another brokerage if itwould be more cost effective or provide better service for the client. On an exception basis, thebrokerage may provide routine trips for special medical needs from adjoining counties.CONFIDENTIALITYBy State and federal law, the Medicaid Transportation brokerage is required to maintain clientconfidentiality except with regard to such information as is necessary to authorize and ordermedical transportation. All brokerage staff is required to sign a Confidentiality Statement.You must not relay personal information about clients or medical diagnoses to thetransportation providers. You may relay information that is important to meeting the client'sneeds such as: Physical limitations, Need for assistance, including entering or exiting a vehicle, or getting to and from thevehicle and home or medical office, Special equipment used by client, and Emotional or mental problems affecting client during transport.Sharing or Inquiries about a clientSometimes callers want to share or request information about a client. Staff must be verycareful under both circumstances following these procedures: If a caller wants to “tell” something about a client or their use of transportation, referthem to your supervisor or brokerage manager. You must not make the caller aware thatyou know the client or provide services for the client under any circumstance. If the caller is a case manager or other branch representative, ask the caller for theirbranch number and case manager ID code. If they are unable to provide this information,ask for a telephone number where they can be reached. Verify the information with thebranch office, and return the call. The brokerage can share all information about a clientwith the branch case manager or branch representative. If a caller says they need client information, including personal but non-medicalinformation such as the client’s address, do not provide the information. Take a messageand assure the caller that their request will be followed up (again, do not verify that theNon-Emergent Transportation Services Brokerage Manual5
client is served by the brokerage). You can call the client and give them the informationor relay the information to the client's branch. When in doubt, check with the supervisor or brokerage manager.CALL TAKINGYou may receive calls from Medicaid clients, case managers, hospitals, nursing facilities, orclient advocates such as family members or neighbors requesting rides. Regardless of the caller,remain courteous and helpful at all times. Always refer to clients as Mr., Mrs., or Miss and theirlast name.Acknowledge clients for being responsible to call early or when they have the informationneeded readily available. CSRs can say things such as “Thank you for calling us well inadvance” or “Thank you for having all the information ready for us.”Abusive CallersThe brokerage staff is not expected to continue a conversation when the caller becomes verballyabusive. The staff member should let the caller know that they are going to hang up, then do so.Any incident which results in the brokerage terminating the call because of inappropriatelanguage, insults or threats should immediately be reported to the supervisor or brokeragemanager and documented as an incident report.Under no circumstances should any staff member use abusive language or in any way threatenor insult a caller.ELIGIBILITY VERIFICATIONThe brokerage shall verify Medicaid eligibility of persons who request transportation to medicalservices. In order to be transported to a covered medical service, the client must be currentlyeligible under the Medicaid Program and receiving coverage through the OHP Plus benefitpackage (BMD, BMH, BMM or CWX).To determine client eligibility for medical assistance transportation:1. Ask the caller for the client name and enter it into the computer.2. If the client cannot be located by name, ask for the client ID number (the identificationnumber on their Oregon Health ID or Medical Care ID.).3. Use one of the following tools to verify the client’s eligibility:a. The Provider Web Portal at https://www.or-medicaid.gov;6OHA – Division of Medical Assistance Programs
b. Daily eligibility download provided by the Division of Medical AssistancePrograms (DMAP);c. DMAP Provider Services (800-336-6016 ); ord. Automated Voice Response (866-692-3864).4. If client eligibility cannot be determined by any of the above methods, call the client'sbranch office and have them verify client eligibility by document submission.5. If eligibility cannot be verified, transportation cannot be authorized. Document caller’sname, address, and phone number to use for a denial letter.6. When authorizing rides in advance of the date of actual service, re-verify eligibility onthe actual date of service to ensure client status has not changed.MEMBER ENROLLMENT VERIFICATIONIn order to identify which agency to work with, the brokerage shall determine if the eligibleclient is enrolled in a coordinated care organization (CCO) or receiving services under DMAP.Use one of the following tools to determine CCO enrollment: The downloads provided by CCOs listing their members; The daily eligibility download provided by DMAP, showing clients not enrolled in aCCO who is responsible for NEMT; The Provider Web Portal at https://www.or.medicaid.gov; DMAP Provider Services at 800-336-6016; or The AVR at 866-692-3864.When authorizing rides in advance of the date of actual service, re-verify CCO enrollment onthe actual date of service to ensure the client’s status has not changed.AUTHORIZATION OF TRANSPORTAfter verification of eligibility for Medicaid Transportation, the brokerage completes theauthorization as follows:1. Determine if the request is for transportation to a covered (See Appendix D) medicalservice.2. Verify that medical services being provided out-of-state (in non-contiguous areas beyond75 miles from the Oregon border)are prior authorized by contacting the client’s CCO,managed care plan, case manager or DMAP Out-of-State Coordinator. Once you verifyNon-Emergent Transportation Services Brokerage Manual7
that the medical services are authorized, you can approve and make arrangements for thetransportation.3. Screen all clients for alternative transportation resources each time they requesttransportation. Key questions to ask:a. Do you have some way you can get to your medical appointment (e.g., friend,relative, or neighbor)? Do you own a car?b. How did you get to your last medical appointment?c. How far do you live from the nearest bus stop?d. Is there some reason you cannot use the bus?e. Has anything changed since the last time you used transportation? If so, what?f. Is there someone who could volunteer to provide transportation if they receivedmileage reimbursement?g. Do you have all required paperwork for your appointment?4. You may authorize multiple trips at one time, from the same location to the same medicalprovider and enter them into the data base. Authorize no more than one month at a timewith the exception of life-sustaining rides such as dialysis which can be authorized fortwo months or more at a time.5. All information must be entered into the computer data base. If the computer is down,verify eligibility by calling the Automated Voice Response at 866-692-3864or thebranch, and hand write the trip information on forms provided for later entry into thecomputer.Screening Procedure1. Assess the client’s need for transportation:a. Is the client Medicaid–eligible?b. Is the client enrolled in a CCO? If so, follow the CCO’s procedures.c. Is the client going to OHP-covered medical service? (Note: the services could bepaid by another source such as Medicare or private insurance, but must be a serviceMedicaid would cover)d. Are other transportation resources available to the client?2. Assess the client’s ability:8OHA – Division of Medical Assistance Programs
a. Is the client ambulatory?b. Client age – If the client is under 12years of age, he or she must have an escort.c. Does the client have assistance available (e.g., escort or personal care attendant)?3. Assess the client’s special conditions or needs:a. Does the client have a physical disability or medical condition which affects theability to use public transportation?1) May require letter from physician;2) Non-bus transportation may be authorized until receipt of physicianverification.b. Is the client mentally challenged?1) What is the client’s level of functioning?2) Are there safety issues regarding transport of the client? Who is at risk,what is the risk?3) Is the client able to learn how to use fixed-route transportation?c. Emotional issues:1) Is there a safety risk due to the client’s emotional status? Who is at risk,what is the risk?2) Will the client go to the appointment on fixed-route?4. Determine level of transport:a. If the client is not able to use fixed-route transportation - Assign appropriate nonbus transport.b. If the client appears able to use a bus - Continue with assessment.5. Assess appropriateness of authorization of bus transport:a. Is the client capable of using fixed-route?b. Does the client already have a bus pass?c. Assess specific trip characteristics:Non-Emergent Transportation Services Brokerage Manual9
1) Distance from bus stop2) Number of transfers needed3) Accessibility of stop4) Safety in accessing bus5) Length of tripd. If there are no barriers or issues regarding use of fixed-route bus, authorize bustickets or pass.e. If a fixed-route is determined not appropriate, authorize alternate transport.Closest Provider of TypeDo not transport clients for long distances for routine medical care. While clients are free tochoose any medical provider, transportation is only available to the nearest appropriateprovider. Inform clients that transportation benefits may not be available if they choose aprovider out of their local area.You may ask clients if there is a reason they do not see a closer medical care provider. If aclient is uncertain, ask their medical care provider or CCO if it is essential that the clientcontinue with the same medical care provider. Make decisions on an individual basis taking intoaccount the client’s enrollment in a managed care plan or CCO, medical necessity, emotionalconsequences, and other factors affecting the client that may make it reasonable to continuewith the same medical provider. It is appropriate to re-examine individual exceptionsperiodically to ensure the client’s current needs are addressed.Clients who do not change to local medical providers, even though there appears to be noqualifying reason to continue with the same out-of-area medical provider, will be denied futuretransportation to that provider. Clients may appeal to DMAP and will continue to receivemedically-appropriate rides until DMAP makes a final decision on the appeal. The client canchoose where to go for medical care but Medicaid Transportation is not obligated to transpor
Non-Emergent Transportation Services Brokerage Manual 1 DEFINITION OF TERMS Advocate - An individual or other entity requesting services on behalf of the client. After Hours - A trip provided when the brokerage is not open. Clients may call the transportation provider directly for a trip when brokerage staff is not available to authorize a
Van Taxi NEMT other Personal vehicle Public transportation Airplane Notes:NEMT is non-emergency medical transportation. FYE is full-year equivalent. Ride-days are defined as days with an NEMT procedure code. A ride-day can have multiple modes of transportation, and percentages do not add to 100.
an independent evaluation of NEMT to 'allow the state and CMS to consider the impact of the state's NEMT policies on access to care.'2 CMS approved the state's plan for this evaluation, which outlined the parameters of the evaluation that Indiana would perform for the NEMT waiver. The results of that evaluation are included in this report.
The North Carolina Department of Health and Human Services, Division of Medicaid Assistance (DMA) has contracted for consultant services to perform compliance reviews of each County Non-Emergency Medical Transportation (NEMT) program. The reviews will be conducted on-site following a desk review.
Non-emergency MEDICAL transport (NEMT) includes the transportation of sick, injured, convalescent, infirm or otherwise incapacitated beneficiaries by ambulance, litter vans, or wheelchair vans. The beneficiary requires door to door service. Requires a prescription from medical provider. Emergency medical transport (EMT) is transportation for an .
Rides through the BCBSTX VAS program are for Non ‑Emergency Medical Transportation (NEMT). This VAS is for BCBSTX CHIP and CHIP Perinate members who have no other way to get to their health care appointments or BCBSTX member events. BCBSTX works with LogistiCare, our VAS transportation provider, to provide your free VAS transportation .
Nonemergency Medical Transportation (NEMT) Services Handbook EFFECTIVE DATE. August 1, 2021 Version 2.0.1 . DOCUMENT HISTORY LOG STATUS. 1. DOCUMENT REVISION. 2. EFFECTIVE DATE DESCRIPTION. 3. Baseline 2.0 May 4, 2021 Initial version Uniform Managed Care Manual Chapter 16.4, Nonemergency Medical Transportation (NEMT) Services Handbook.
emergency transportation services. Members should dial 9-1-1 if immediate response is needed for emergencies or worsening conditions that threaten life or limb. LogistiCare is a transportation coordinating company contracted with the Virginia Department of Medical Assistance Services (DMAS) to manage Fee for Service (FFS) Non-
Transportation for Nursing Home Residents, and, Transportation for rehabilitation services unless the rehabilitation services have been authorized by the Prior Authorization Unit . Note: Transportation for the initial visit for an evaluation for the need of rehabilitation services will be approved by the Transportation Dispatch Office.
