Mercy Care, through our external auditing vendor, have been conducting program integrity reviews of transportation providers as well as other outpatient providers that provide transportation. Non-emergency transportation (NEMT) is an area in which there is potential risk to providers and to the health plans. There has been concern in the past over the potential for fraud, waste and abuse via non-emergency transportation billing which resulted in AHCCCS publishing more stringent guidelines in terms of what should be expected in the documentation and who can provide these services.
In light of the results from the most recent transportation reviews, Mercy Care has determined that a provider notice regarding NEMT requirements would be helpful in reminding providers of what is required in terms of billing guidelines and documentation guidelines for these services.
Chapter 14 of the AHCCCS FFS Provider Manual states the following:
When free transportation services are unavailable and an eligible person is unable to arrange or pay for transportation, AHCCCS covers medically necessary non-emergency medical transportation to and from an AHCCCS covered medical or behavioral health service for most recipients. Non-emergency medical transportation is not covered for Emergency Services Program recipients. Transportation is limited to the cost of transporting the recipient to the nearest AHCCCS registered provider capable of meeting the recipient’s medical needs. Transportation must only be provided to transport the recipient to and from the required, AHCCCS covered medical or behavioral health service.
Please note that AHCCCS expects that the services are for covered medical and behavioral health services. Services should be limited to the cost of transporting the member to the nearest AHCCCS registered provider capable of meeting the member’s needs. There may be exceptions related to member choice, etc., but in general, the transportation should be to the nearest AHCCCS registered provider. The AHCCCS Covered Behavioral Health Services Guide notes the following
:
Transportation services involve the transporting of a person from one place to another to facilitate the receipt of, or benefit from, medically necessary covered behavioral health services, allowing the person to achieve their service plan goals.
Please note that while this allows the person to receive transportation services to achieve their service plan goals, the services should be for medical necessary covered services and not simply to locations in which the member can benefit from their service plan goals. This could be argued to be anything or any location. We are charged with being good stewards of federal and state funds and we should be cognizant of utilizing these services in the most conservative manner possible while still allowing the members to benefit from the needed covered services.
For NEMT, there are two different billing scenarios:
- Loaded transportation (the member is with the staff)
- Provider travel (the provider is traveling to where the member is to provide a service)
The AHCCCS FFS Manual Chapter 14 states the following regarding loaded mileage:
Non-emergency transportation providers must bill the number of trips and the number of loaded miles as units of service on the CMS 1500 claim form. Loaded mileage is defined as the distance traveled,
measured in statute
miles, with a recipient on board the vehicle and being transported to receive medically necessary AHCCCS covered services.
For all providers, please note that
loaded transportation
services should be billed with both the appropriate base rate (A0100, A0120) and the associated mileage (S0215). Claims/encounters should not be submitted without both codes for loaded transportation services. Mileage and base rate does not begin until the member is in the vehicle with the driver. The transportation to pick-up the member is not billable in terms of mileage or time.
For
provider travel
, the member is not in the vehicle with the staff. The staff is traveling to where the member is to provide a service. This is billed utilizing code A0160 only. Please note as per the AHCCCS Covered Behavioral Health Services Guide that this code is not billable for the first 25 miles. The first 25 miles are unencountered. The only mileage that can be billed is mileage over the 25 mile threshold. This is true for each segment of the trip. This code is not billable to for travel time/mileage when going to pick up the member for loaded transportation.
In terms of documentation, it was noted during the most recent audit that many providers are not appropriately capturing the required documentation as noted by Chapter 14 of the AHCCCS FFS Provider Manual (which states that it is the provider’s responsibility to maintain documentation that supports each transport service claimed) and the AHCCCS Covered Behavioral Health Services Guide. These requirements are also noted in the Mercy Care Provider Manual Chapter 4. Each NEMT service must have the following documentation noted:
- Complete transport service provider’s name and address
- Printed name and signature of the driver who provided the service
- Vehicle identification (license # and state)
- Vehicle type (car, van, wheel chair van, stretcher, etc.)
- Recipient’s full name
- Recipient’s AHCCCS ID#
- Recipient’s date of birth
- Complete date of service, including month, day and year
- Complete address of pick up destination
- Time of pick up
- Odometer reading at pick up
- Complete address of drop off destination
- Time of drop off
- Odometer reading at drop off
- Type of trip – one way or round trip
- Escort name and relationship to recipient being transported
- Signature (or fingerprint) of recipient verifying services were rendered
AHCCCS does provide further clarification on the recipient signature. The following requirements should be noted:
- If the member is unable to sign or utilize a fingerprint, the parent/guardian, caretaker/escort or family member can sign for the member. The relationship to the member must be noted.
- If the member that is unable to sign is traveling alone, the trip report may be signed by the provider at the medical or behavioral health service appointment.
- The driver can never sign for the member.
Please ensure that documentation for NEMT includes all items as noted above. Documentation via a spreadsheet or screenshots of maps does not capture all of the required elements.
In terms of the base rate billed under A0120, while AHCCCS allows 5 units of this service to be billed per day per member, Mercy Care strongly recommends that only 2 units of this service be billed per day – once at the initial pickup and the second unit when the loading occurs to take the member home. While there may be intermittent stops during the trip, there is not sufficient reason to bill those additional units, as the intent is not to start the transportation over, but rather to simply reload the member to continue the trip.
We would also like to remind providers of our previous provider notice regarding NEMT over 100 miles. Any NEMT service over 100 miles will require submission of a trip ticket or EDI information noting the complete pick-up and drop off locations for review prior to payment. Any NEMT over 100 miles without the required documentation will result in a claim denial.
Please always ensure that the following eligibility and service guidelines are adhered to when providing NEMT services as noted in AHCCCS AMPM Manual Policy 310-BB on Transportation:
Medically necessary NEMT is covered consistent with A.A.C. R9-22-211 when furnished by NEMT providers to transport a member to and from a
covered
physical or behavioral health service.
Medically necessary NEMT is covered as noted below
:
- The service the member is being transported for, whether physical health or behavioral health, is a covered AHCCCS service;
- The member is unable to provide, secure or pay for their own transportation, and free transportation is not available; and
- The transportation is provided to and from the nearest appropriate AHCCCS registered provider.
If the member is unable to provide, secure or pay for their own transportation and free transportation is not available, NEMT services are also covered under the following circumstances:
- Transport the member to obtain Medicare Part D covered prescriptions; and
- Transport the member to participate in local community based support programs which must be identified in the member’s service plan. Transportation is covered only when transporting the member to the nearest program capable of meeting the member’s needs as identified on the member’s service plan. Covered local community-based support programs are limited to those specified in Attachment A of Policy 310-BB and are noted below:
- Alcoholics Anonymous (AA)
- Narcotics Anonymous (NA)
- Cocaine Anonymous
- Crystal Meth Anonymous
- Dual Recovery Anonymous
- Heroin Anonymous
- Marijuana Anonymous
- Self-Management and Recovery Training (SMART Recovery)
- National Alliance on Mental Illness (NAMI) Family Support
- Living Well with a Disability and Working Well with a Disability Program
As always, don't hesitate to contact your Mercy Care Provider Relations Representative with any questions or comments. You can find this notice and all other provider notices on our
Mercy Care
website.
Thanks for all you do!
