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Local County or Tribal Agency Nonemergency Medical Transportation (NEMT) Services Claim, Service, and Rate Information

Revised: 12-12-2016

  • Overview
  • Claim Information
  • Procedure Codes, Modifiers and Payment Rates
  • Overview

    County and tribal agency requests for MHCP reimbursement for nonemergency medical transportation (NEMT) service and ancillary services must be billed electronically through MN–ITS interactive or batch.

    Local agency administered NEMT and the ancillary service claim submissions require a number of fields to be completed with correct and accurate information for the claim to process and pay. This section has general information for basic claim submission. Additional requirements may be necessary for access transportation and the related ancillary services claims to be billed and reimbursed correctly.

    This information is effective for dates of service on and after July 1, 2016.

    Claim Information

    Basic claim information includes:

  • Pay-to provider number: Local agency (county or tribe) provider number
  • Individual subscriber ID: MHCP ID (MA ID) number of the MHCP eligible individual who received the covered medical service for which the NEMT transport or ancillary service(s) were provided or reimbursed
  • • Diagnosis Code: Z02.9 – Encounter for Administrative Examinations; Unspecified. Valid for dates of service on or after October 1, 2015
  • Claim submission requires each service provided (each code) to be billed on a separate service line. Proper claim submission requires entry of the following:

  • • Date(s) of service (DOS)
  • • Dates on claim limited to one calendar month
  • • Enter single date when service is provided on one date only
  • • Enter “From-To” date span for multiple consecutive dates of the same service. A date span does not include a date the service was not provided
  • • Service (procedure) code: Reflects the NEMT transport service provided or reimbursed as indicated in the tables below in this section
  • • Enter a separate claim line for each distinct service code submitted
  • • Multiple services within same calendar month can be included on the same claim
  • • Modifier: Indicates the level of service provided when the service includes more than one level or type of transport as indicated in the tables below in this section
  • • Service unit count: Reflects the total number of units of service provided for the date(s) and service type entered. Example: A0090 (personal mileage) = 30 miles = 30 units
  • • Line item charge amount: Reflects the total reimbursement amount requested for the service units billed on the line. Example: A0090 (personal mileage) = 30 miles = 30 units x $0.20/unit = $6.00 total line item charge amount
  • Submit claims for the appropriate transportation base and mileage rates for transport of an MHCP member with the service code and modifier(s) combinations listed on the table.

    Local County or Tribal Agency–Administered Transportation Procedure Codes, Modifiers and Payment Rates

    Procedure codes and payment rates effective for dates of service on and after July 1, 2016

    Procedure Code

    NEMT Service Description

    Service Modifier

    Payment Rate
    Effective 9/1/2013

    A0100
    Unassisted Transport Base (Mode 3)

    Taxi or equivalent, curb-to-curb

    Origination and destination identifier modifier

    Base rate: $11.00
    (limit of 2 units per service line)

    S0215*
    Unassisted Transport Mileage

    Taxi or equivalent, curb-to-curb

    Origination and destination identifier modifier

    Mileage rate: $1.30 per mile beginning with mile one/first loaded mile

    T2003
    Assisted Transport Base (Mode 4)

    Nonemergency transportation; ambulatory; encounter or trip = door-to-door and door-through-door

    Origination and destination identifier modifier

    Base rate: $13.00
    (limit of 2 units per service line)

    S0215*
    Assisted Transport Mileage

    Nonemergency transportation mileage; ambulatory; encounter or trip = door-to-door and door-through-door

    Origination and destination identifier modifier

    Mileage rate: $1.30 per mile beginning with mile one/first loaded mile

    * The transport claims must have a paid base service line to reimburse the mileage service line charges.

    Multiple Unassisted and Assisted Transports on the Same Date of Service
    Billing for the base (pick-up) service code is limited to two units per service line per date of service (DOS). If the person is provided more than two transports on the same DOS, separate the base charges into two units per service line billed and include the “repeat service” modifier on the additional base service line(s).

    Bill the corresponding mileage on multiple service lines consistent with the base service lines billed.

    Modifiers Required

    For “Mode 4 – Assisted Transport” base (T2003) and mileage (S0215) an origination (pick-up) and destination (drop-off) identifier modifier combination is required. The modifier is determined by combining two individual location identifiers. The first indicator is the origination identifier and the second identifier is for the destination. Indicators for for the modifer are created from the identifiers used for Medicare ambulance billing. The indicators include the following:

    D = Diagnostic or therapeutic site other than P or H when these are used as origin codes
    E = Residential, domiciliary, custodial facility (other than 1819 facility)
    G = Hospital based ESRD facility
    H = Hospital
    I = Site of transfer (for example, airport or helicopter pad) between modes of ambulance transport
    J = Freestanding ESRD facility
    N = Skilled nursing facility
    P = Physician’s office
    R = Residence
    S = Scene of accident or acute event
    X = Intermediate stop at physician’s office on way to hospital (destination code only)

    Personal and Volunteer Driver Mileage

    Procedure codes and payment rates for personal and volunteer drivers

    Procedure Code

    NEMT Service Description

    Service Modifier

    Payment Rate

    A0090

    Vehicle provided by individual (self, family member, neighbor, others) with vested interest

    None

    On and after 7/1/2016:
    $0.22 per mile

    A0090
    Licensed Foster Parent

    Vehicle provided by licensed foster parent only

    UC*

    1/1/2016 – 12/31/2016:
    $0.54 per mile

    A0080
    Volunteer Driver

    Vehicle provided by volunteer (individual or organization) with no vested interest

    None

    1/1/2016 – 12/31/2016:
    $0.54 per mile

    * A0090 = Personal Mileage Code with “UC” modifier is used to indicate volunteer mileage rate reimbursement paid only to a licensed foster parent.

    Bus, Paratransit and Air Travel

    Procedure codes and payment rates for bus, paratransit and air travel

    Procedure Code

    NEMT Service Description

    Service Modifier

    Payment Rate

    A0110

    Bus, intrastate or interstate carrier (includes light rail)

    None

    At cost; reimbursement cannot exceed rate paid by non-MHCP passengers;
    RUCA does not apply

    A0110

    Bus, monthly pass (includes light rail)

    U7

    At cost; reimbursement cannot exceed rate paid by non-MHCP passengers;
    RUCA does not apply.

    A0120

    ADA paratransit

    None

    At cost; reimbursement cannot exceed rate paid by non-MHCP passengers;
    RUCA does not apply.

    A0140

    Air travel (private or commercial) intra/interstate, when appropriate

    None

    At cost; reimbursement cannot exceed rate paid by non-MHCP passengers.
    Need not be direct flight;
    RUCA does not apply.

    Rural Urban Commuting Area (RUCA) Adjustments Add-ons

    Effective for dates of service on and after July 1, 2016, transport of clients meeting residence zip code classifications of urban, rural, and super-rural will, in some situations allow additional reimbursement or add-on to the provider.

    For reimbursement for nonemergency medical transportation RUCA adjustments for modes 1 through 7, the ZIP code of the recipient's place of residence determines whether the urban, rural, or super-rural reimbursement rate adjustment applies.

    Transport Base RUCA Adjustments
    The base rate, when paid for nonemergency medical transportation services in areas defined under RUCA to be super-rural, is equal to 111.3 percent of the respective base rate if applicable for modes 1 through 7.

    Transport Mileage RUCA Adjustments
    The mileage rate for nonemergency medical transportation services in areas defined under RUCA to be rural or super-rural areas is as follows:

  • • For a trip 17 miles or less, the mileage rate is equal to 125 percent of the respective mileage rates for modes 1 through 7
  • • For a trip between 18 and 50 miles, the mileage rate is equal to 112.5 percent of the respective mileage rate for modes 1 through 7.
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