CurrentBlue Cross Blue Shield - WisconsinPolicy N/A

Medical Request of Individual Level of Non-Emergent Medical Transportation (NEMT) Service

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Governance and instructions for completing a practitioner-signed form to request or confirm a higher level of NEMT service for Medicaid members; affects practitioners, WellTrans (the NEMT broker), and members seeking NEMT services.

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyMedical Request of Individual Level of Non-Emergent Medical Transportation (NEMT) Service

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionPractitioner must complete and sign Section II certifying medical need and submit the form via fax, mail, or secure email after coordinator review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1/4 miledistance threshold to public transit stop

1 yearform retained on file

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CurrentBlue Cross Blue Shield - WisconsinPolicy N/A

Medical Request of Individual Level of Non-Emergent Medical Transportation (NEMT) Service

Customize your policy alerts

Sign up for all Blue Cross Blue Shield - Wisconsin policy alerts

Know when Blue Cross Blue Shield - Wisconsin releases new policies or updates existing guidance.

Monitor payer policy activity

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Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyMedical Request of Individual Level of Non-Emergent Medical Transportation (NEMT) Service

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionPractitioner must complete and sign Section II certifying medical need and submit the form via fax, mail, or secure email after coordinator review.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1/4 miledistance threshold to public transit stop

1 yearform retained on file

Mon-Fri 8am-6pmWellTrans hours

317-541-1250fax for submission

Coverage Criteria for NEMT Level Assignment

Public Transportation assignment criteria

Assign public transit when ALL of the following are met:

Public transit assignment: Member's residence is within 1/4 mile of a public transit stopdistance <= 1/4 mile

CSR screens and may consider mitigating factors such as age, neighborhood safety, and weather

Public transit assignment: Member can enter and exit their home and the healthcare facility without assistance

Public transit assignment: Member does not have a physical or mental impairment that prevents use of public transit

Public transit assignment: Member is not receiving treatment or therapy for a complex medical diagnosis (for example, chemotherapy or dialysis)

Higher-level NEMT approval criteria

Higher-level NEMT (ambulatory, wheelchair, attendant) is provided when ALL of the following are met:

Practitioner attestation: Practitioner completes Section II certifying the member's medical need prevents use of a lower level of transportationsigned practitioner attestation

Form is required only after the Anthem transportation coordinator cannot confirm the member's request

Practitioner attestation details: Practitioner indicates whether accommodation is temporary or permanent, selects the type of transportation needed (public transportation, common passenger, wheelchair, attendant), provides estimated timeframe and clinical rationale, prints name, provides Medicaid provider ID, signs and dates the form

Individuals receiving complex medical treatments (for example, chemotherapy or dialysis) are not assigned to public transportation. The CSR screening for public transit explicitly excludes members who are undergoing treatment or therapy for a complex medical diagnosis from being placed on public transit.

Assigning public transit is inappropriate when a member has impairments or needs assistance that would prevent safe use of public transportation. Specifically, public transit should not be assigned if the member has a physical or mental impairment that prevents public transit use, or if the member cannot enter or exit their home or the healthcare facility without assistance. Members receiving complex therapies are likewise excluded from assignment to public transit.

Coding and Distance Thresholds

Distance to public transit stop

Distance thresholdMember's residence is within 1/4 mile (<= 1/4 mile) of a public transit stop.

Mitigating factorsAge, medical condition, neighborhood safety, and inclement weather may be evaluated when applying the distance threshold.

CSR roleCustomer service representative screens whether assigning public transit is appropriate based on distance and other criteria.

Provider Responsibilities and Workflow

Prior Authorization

Practitioner form required after coordinator review

Use this practitioner-signed form only after the Anthem transportation coordinator has attempted to confirm or deny a member's request for a higher level of NEMT; the form is sent to the practitioner when the coordinator cannot confirm the request.

Step Therapy

Level assignment workflow

WellTrans screening assigns the lowest appropriate level of transport (public transit, ambulatory, wheelchair/non‑ambulatory, or attendant) based on the criteria in the definitions; a higher-level transport requires practitioner assessment and signature when the coordinator cannot confirm the member's request.

CSR determines if pickup/drop-off are on a public bus route and screens against public transit criteria (distance, ability to enter/exit, impairments, complex therapies).

Background

Nonemergent medical transportation (NEMT) is a Medicaid-covered benefit for travel to and from Medicaid providers. When an individual calls to schedule NEMT, a customer service representative (CSR) screens pickup and drop-off locations and the member's condition to determine the appropriate level of transport. The CSR evaluates whether the member meets the public transportation criteria — including residence within 1/4 mile of a public transit stop, ability to enter and exit home and facility without assistance, absence of physical or mental impairments preventing transit use, and not receiving complex medical treatments — and also considers mitigating factors such as age, neighborhood safety, and weather when making the determination.

Key Definitions

Public Transportation

DefinitionPickup and drop-off locations are on a public bus route.

Distance requirementMember's residence is within 1/4 mile of a public transit stop.

Functional abilityMember must be able to enter and exit home and healthcare facility without assistance.

Clinical exclusionsMember must not have a physical or mental impairment preventing public transit use and must not be receiving complex therapies (e.g., chemotherapy or dialysis).

Ambulatory Transportation

DefinitionFor individuals who do not need equipment to travel and who are able to walk or only need basic assistance.

Policy Summary

PayerBlue Cross Blue Shield - Wisconsin

PolicyMedical Request of Individual Level of Non-Emergent Medical Transportation (NEMT) Service

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionPractitioner must complete and sign Section II certifying medical need and submit the form via fax, mail, or secure email after coordinator review.

SourceLink

On This Page

Documentation Required

Required practitioner documentation and submission

Practitioner must complete Section II of the form certifying whether the member's medical need requires the requested accommodation, indicate Temporary or Permanent, select the type/level of service, provide an estimated timeframe and an explanation, print name, provide Medicaid provider ID, and sign and date before submitting.

Submission methods: fax 317-541-1250, mail to 7155 Shadeland Station Way, Suite 190, Indianapolis, IN 46256, or secure email to mnr@welltransnemt.com.
Estimated timeframe options include 30, 60, 90, 120, 180, 365 days or Other.

Denial Risk

Triggers for denial

Requests may be denied if the member can use public transit — e.g., residence within 1/4 mile of a public transit stop, able to enter and exit home and facility without assistance, has no physical or mental impairment preventing public transit use, and is not receiving complex therapies — or if the practitioner does not support the requested higher-level transport.

Public transit distance threshold: 1/4 mile; mitigating factors (age, safety, weather) may be considered.
Complex therapies (for example, chemotherapy or dialysis) are exclusions to public transit assignment.

Common vehicle or taxi; does not require specialized medical equipment.

Use caseAssigned when member cannot use public transit but does not require wheelchair or attendant-level services.

Non-ambulatory Transportation

DefinitionWheelchair transport for individuals who must travel in a wheelchair and cannot transfer to a common vehicle.

Vehicle featuresProviders are generally upfitted with specialized medical equipment such as permanently installed ramps and lifts for wheelchairs.

Patient limitationFor members confined to their wheelchair or unable to transfer independently.

Accompanying Adult

DefinitionAn attendant or escort provided for individuals who require assistance with mobility, personal care, or other functions during travel or the appointment.

ScopeAccompanying adult supports travel and stays with member to assist as needed to complete the appointment.

When usedAssigned when member's needs exceed what the driver or transport alone can safely provide (mobility, personal care).