Non-Emergency Medical Transportation (NEMT) Coverage Criteria
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Defines Alliance Health coverage determinations, clinical criteria, prior authorization requirements, and exclusions for Non-Emergency Medical Transportation for members enrolled in the Alliance Health Tailored Plan (North Carolina Medicaid). Applies to coverage decisions for NEMT only.
Added policy hierarchy and scope language clarifying that federal/state law, NC Medicaid policies, EPSDT, and the NC Medicaid Tailored Plan Contract supersede this policy.
Clarified eligibility & EPSDT and structured clinical coverage criteria including a defined prior authorization review hierarchy.
Elevated prior authorization triggers including medical director review for air transport, out-of-state transport, and when distance exceeds standard thresholds.
Refined limitations and exclusions for NEMT, including facility responsibilities and waiver services that include transportation.
Coverage Criteria for Non-Emergency Medical Transportation
Covered when ALL criteria met
Alliance covers NEMT when ALL the following are met:
Full nested logic and definitions included within the text
NEMT is not covered when transportation is already provided by another authority or setting. Examples include residents of nursing facilities or long-term care facilities where the facility is responsible for transportation and members who are admitted to an inpatient hospital when transportation is part of facility-provided care. NEMT is also excluded when transportation is included within certain waiver services during hours of service delivery (for example, Innovations Day Supports, Respite, Community Living and Support; TBI Day Supports, Community Networking, Supported Employment).
Additional non-covered scenarios include trips to providers chosen solely for member or provider preference when closer appropriate options exist, and transportation for services that are not covered, not authorized, or not medically necessary. Incidental stops during a trip are not covered. Transportation to a more distant provider is allowed only when the required service is not available closer or there is documented clinical necessity or access limitation. Exceptions may be made under EPSDT or when transportation is otherwise unavailable but the trip meets the policy’s clinical coverage criteria and prior authorization requirements.
Coding & Thresholds
Provider Actions, Prior Authorization & Documentation
Prior authorization triggers
Prior authorization is required for trips greater than 75 miles one-way and for transportation itineraries that include overnight lodging. In addition, medical director review is required for air transport, out-of-state transportation, and when distance exceeds standard thresholds.
PA review hierarchy
When evaluating medical necessity and mode selection, Alliance applies a prior authorization review hierarchy that uses NCDHHS Clinical Coverage Policies, Alliance Clinical Coverage Policies, and MCG criteria.
Required documentation and templates
Documentation must demonstrate medical necessity, the selected transportation mode, trip distance, and that the member lacks both the means and mode to arrange transportation. Providers must use the Clinical Specialist and Medical Director templates in Alliance's healthcare management platform to meet documentation standards for utilization management and medical director review.
Triggers for denial
Authorizations may be denied if the member has the means or mode to arrange transportation, the trip is not to a Medicaid-covered service or is not medically necessary, the trip includes incidental stops, transportation is provided under another authority or setting, or the destination was chosen solely for preference when closer appropriate options exist.
- Member has means and/or mode to arrange transport independently
- Trip is not to a Medicaid-covered service, is not authorized, or is not medically necessary
- Trip includes incidental stops
- Transportation is otherwise provided by a facility, long-term care, or included in a waiver service during hours of service delivery
- Destination/provider chosen solely for member or provider preference when closer appropriate options are available
Background
Non-Emergency Medical Transportation (NEMT) provides covered transportation for Medicaid members who cannot safely or affordably arrange travel to access Medicaid-covered services. Coverage is based on medical necessity, the member’s lack of both means and mode to arrange transport, the destination being a Medicaid-covered service furnished by a North Carolina Medicaid-enrolled provider, and selection of the least costly appropriate mode that is safe and appropriate for the member’s clinical condition. NEMT is limited to travel for the member’s direct clinical care with no incidental stops and to the nearest appropriate provider able to deliver the approved service; reasonable travel time and distance consider urgency, functional limitations, appointment availability, and required transportation modality.
Definitions
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