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    v1.0.30
    OpenPayerPolicy UpdatesEmergency & Medical TransportationAHCCCS NEMT Coverage Prior Authorization | OpenPay…
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    CurrentArizona Health Care Cost Containment SystemPolicy N/A

    Medically Necessary Non-Emergency Transportation (NEMT) Coverage Criteria

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    This policy governs AHCCCS coverage and prior authorization requirements for medically necessary non-emergency transportation when a member needs transportation to or from a covered medical or behavioral health service and cannot provide, secure, or pay for transportation.

    Policy Summary
    PayerArizona Health Care Cost Containment System
    PolicyMedically Necessary Non-Emergency Transportation (NEMT) Coverage Criteria
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateN/A
    Next Review DateN/A
    Key ActionObtain prior authorization for medically necessary NEMT exceeding 100 miles round trip, unless provided by an IHS/638 provider.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    >100 milesPrior authorization mileage threshold
    Nearest appropriate providerDestination limitation
    IHS/638 exceptionIHS/638 prior authorization exception

    Non-Emergency Transportation Coverage

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Basic NEMT coverage

    NEMT is covered when ALL of the following are met:

    • Covered service: The medical or behavioral health service for which transportation is needed is a covered AHCCCS service.
    • No available member or free transportation: The member is unable to provide, secure, or pay for transportation, and free transportation is not available.
    • Nearest appropriate provider: Transportation is provided to and from the nearest appropriate AHCCCS-registered provider.

    Transportation destination and purpose

    Transportation must meet ALL of the following limitations:

    Transportation limitations

    • Covered-service purpose: Transportation is provided only to and from the required covered medical service.
    • Nearest capable provider: Transportation is limited to the cost of transporting the member to the nearest appropriate AHCCCS-registered provider capable of meeting the member's medical needs.

    AI member transportation destinations

    For AI members, transportation is covered to and from either qualifying location:

    AI member destination options

    • IHS/Tribal 638 facility: The nearest appropriate IHS/Tribal 638 medical facility is located either on-reservation or off-reservation.
    • Off-reservation AHCCCS provider: The nearest appropriate AHCCCS-registered provider is located off-reservation.

    Transportation is not covered when the member travels to a provider other than the nearest appropriate AHCCCS-registered provider capable of meeting the member’s medical needs, unless applicable medical necessity justification supports the extended travel. For AI members, covered destinations may include the nearest appropriate IHS/Tribal 638 medical facility, whether on- or off-reservation, or the nearest appropriate AHCCCS-registered provider located off-reservation.

    Prior Authorization Threshold

    NEMT Prior Authorization Mileage Threshold
    Prior authorization thresholdGreater than 100 miles round trip
    Prior authorization requirementPA is required for medically necessary NEMT when the mileage is greater than 100 miles round trip.
    ExceptionPA is not required for IHS/638 providers.

    Authorization, Documentation, and Denial Risks

    Prior Authorization

    PA Required for NEMT Over 100 Miles

    Prior authorization is required for medically necessary NEMT exceeding 100 miles round trip. PA is not required for transportation to IHS/638 providers.

    • >100 miles round trip: obtain PA before arranging transportation
    • IHS/638 providers: PA exception applies
    Documentation Required

    Travel Beyond Nearest Provider

    When NEMT is requested beyond the nearest appropriate facility or provider, AHCCCS may request medical-necessity justification to confirm that NEMT coverage requirements are met.

    • Be prepared to justify why travel beyond the nearest appropriate facility or provider is medically necessary
    Documentation Required

    Physician Order and Medical Necessity Documentation

    The provider ordering the covered AHCCCS service should submit the requested physician’s order and medical-necessity documentation directly to AHCCCS FFS. The order should include medical justification for travel outside the member’s area of residence when applicable.

    • Use the AHCCCS FFS Prior Authorization Medical Documentation Form as the fax cover sheet
    • Fax documentation to AHCCCS FFS at 602-254-2431
    Denial Risk

    Confirm Basic NEMT Eligibility

    NEMT is covered only when the member cannot provide, secure, or pay for transportation and free transportation is unavailable, and the underlying medical or behavioral health service is a covered AHCCCS service.

    • Do not arrange covered NEMT when the service is not covered by AHCCCS
    • Do not arrange covered NEMT when the member can provide, secure, or pay for transportation
    • Free transportation must not be available
    Denial Risk

    Nearest Appropriate Provider Limitation

    Transportation is limited to the cost of transporting the member to and from the nearest appropriate AHCCCS-registered provider capable of meeting the member’s medical needs. Travel beyond that provider may be denied unless the required medical-necessity justification supports the request.

    • For AI members, the destination may be the nearest appropriate on- or off-reservation IHS/Tribal 638 facility, or the nearest appropriate off-reservation AHCCCS-registered provider
    Denial Risk

    Limit the Trip to the Covered Service

    Transportation must be limited to transporting the member to and from the required covered medical service. Trips for destinations or purposes outside that covered service are not included in covered NEMT.

    • Confirm the trip is directly to and from the required covered AHCCCS medical service
    Denial Risk

    Missing Required Prior Authorization

    Medically necessary NEMT exceeding 100 miles round trip may be denied when the required PA is missing, unless the transportation is for an IHS/638 provider.

    • Obtain PA for qualifying trips before transportation is provided
    • The IHS/638 provider exception to PA still applies

    Key Transportation Term

    Medically Necessary Non-Emergency Transportation (NEMT)
    DefinitionNon-emergency transportation services that are medically necessary for travel to and from a covered AHCCCS medical or behavioral health service.
    Covered destinationThe nearest appropriate AHCCCS-registered provider capable of meeting the member's medical needs.
    Covered purposeTransportation must only be provided to transport the member to and from the required covered medical service.
    Policy Summary
    PayerArizona Health Care Cost Containment System
    PolicyMedically Necessary Non-Emergency Transportation (NEMT) Coverage Criteria
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateN/A
    Next Review DateN/A
    Key ActionObtain prior authorization for medically necessary NEMT exceeding 100 miles round trip, unless provided by an IHS/638 provider.
    SourceLink
    On This Page
    Non-Emergency Transportation CoveragePrior Authorization ThresholdAuthorization, Documentation, and Denial RisksKey Transportation Term