CurrentHealth NetPolicy N/A

Non-Emergency Medical Transportation (NEMT) Request / Physician Certification Statement

Governs requirements and medical necessity criteria for Health Net's processing of Non-Emergency Medical Transportation (NEMT) requests for Medi-Cal managed care members in North Carolina, including required provider certification using a Physician Certification Statement (PCS).

Policy Summary

PayerHealth Net

PolicyNon-Emergency Medical Transportation (NEMT) Request / Physician Certification Statement

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionFax a completed, signed Physician Certification Statement (PCS) to Health Net at 833-701-0051 to request NEMT.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Fax: 833-701-0051Where to fax completed PCS

Valid up to 1 yearPCS validity

PCS requiredPCS required

Air transport PAAir transport PA

Multiple modes listedCovered modes

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Criteria for NEMT

inv-01: Wheelchair van coverage

Covered when ALL of the following are met:

Wheelchair van criteria: (A) Patient is incapable of sitting in a private vehicle, taxi, or other form of public transportation for the period of time needed to transport; (B) Patient requires transport in a wheelchair or assistance to/from residence, vehicle, and place of treatment because of a disabling physical or mental limitation (LEA specialized medical transportation services are not subject to subsection (B)1); (C) Requires specialized safety equipment beyond that normally available in passenger cars, taxicabs, or other forms of public conveyance; (D) Does not require ambulance-level specialized services, equipment, and personnel because the patient is in stable condition and does not need constant observation.

inv-02: Litter/Gurney (Stretcher) van coverage

Covered when ALL of the following are met:

Litter van criteria: (A) Patient requires transport in a prone or supine position because incapable of sitting for the period of time needed to transport (LEA specialized medical transportation services are not subject to subsection (A)1); (B) Requires specialized safety equipment beyond that normally available in passenger cars, taxicabs, or other forms of public conveyance; (C) Does not require ambulance-level specialized services, equipment, and personnel because the patient is in stable condition.

inv-03: Ambulance levels of service (BLS, ALS, Specialty Care Transport)

Covered when member meets listed clinical situations for each level:

Basic Life Support (BLS): 1) Transfers between facilities for members who require continuous intravenous medication, medical monitoring, or observation; 2) Transfers from an acute care facility to another acute care facility; 3) Transport for members who have recently been placed on oxygen (does not apply to members with chronic emphysema who carry their own oxygen for continuous use); 4) Transport for members with chronic conditions who require more than 5L of oxygen if monitoring is required; 5) Transport from hospital to psychiatric facility.

Advanced Life Support (ALS): Transport from hospital to hospital with a cardiac monitor.

Specialty Care Transport (SCT): Transports requiring ventilator care, respiratory therapist, deep suctioning, or continuous intravenous medication where skilled personnel or equipment are needed during transport; includes hospital-to-hospital, hospital-to-SNF/residence, and transport to appointments as specified.

inv-04: Air transport coverage

Medical transportation by air is covered under the following conditions:

Emergency air transport: For emergencies, air transport is covered when medically necessary as demonstrated by the required statement and either: (1) the patient’s medical condition precludes other means of medical transportation as indicated in the submitted statement, or (2) the patient or the nearest hospital capable of meeting the patient’s medical needs is inaccessible to ground medical transportation as indicated in the submitted statement.

Must be indicated in the submitted statement per paragraph (b)(1).

Non-emergency air transport: For nonemergencies, air transport is covered when transportation by air is necessary because of the patient’s medical condition or when practical considerations render ground transportation not feasible; necessity must be substantiated by the content of a written order from an authorized provider (physician, podiatrist, or dentist).

Requests for Non-Medical Transportation (NMT) such as private vehicles or public transportation are handled outside the NEMT Physician Certification Statement (PCS) process. NMT requests do not require submission of the PCS and should be directed to Health Net Customer Service at the telephone number provided; the PCS requirement and submission process apply only to Non‑Emergency Medical Transportation (NEMT) services that must be certified by a qualified provider and faxed to Health Net at the specified number. PCS is valid up to 1 year from the provider signature and is required to determine appropriate NEMT mode selection.

Health Net separates NMT from NEMT: NMT requests go through Customer Service while NEMT requests require a completed, signed PCS to establish medical necessity and select the correct transport mode (wheelchair van, litter/gurney van, ambulance, air). The PCS must include all mandatory fields and proper provider signature to be processed; incomplete or unsigned PCS forms may be denied.

Wheelchair van or litter/gurney (stretcher) van services are not appropriate when the member requires ambulance‑level services. Specifically, these non‑ambulance modes are only covered when the patient is stable and does not require the specialized services, equipment, and personnel provided in an ambulance. If the member needs constant observation or skilled clinical interventions during transport (i.e., conditions meeting ambulance criteria), the transport must be provided at an ambulance level rather than by wheelchair or litter van.

Provider Actions, Documentation & Authorization

Prior Authorization

Air transport prior authorization

Air transport (A0430/A0431) requires prior authorization through Health Net. A written order from a physician, podiatrist, or dentist and documentation demonstrating medical necessity must accompany the request. For emergencies, air transport is covered only when ground transport is precluded by the patient's condition or inaccessibility of an appropriate hospital; for non-emergencies, air transport is covered when medical condition or practical considerations make ground transport not feasible.

Affected HCPCS: A0430, A0431
Written order and medical necessity documentation required

Documentation Required

Submission and modification

Once a completed PCS form is submitted by an approved provider, neither Health Net nor the transportation vendor can modify the request. Any changes require a new PCS form submitted by an authorized provider. Providers must fax the completed and signed PCS to Health Net's Care Ride Unit at 833-701-0051.

No post-submission modifications without a new PCS from an authorized signer
Fax completed PCS to 833-701-0051

Documentation Required

Required documentation

Complete all mandatory sections of the PCS. Any field marked with an '*' is required and must be filled out prior to submission. The PCS must be signed by an approved provider type (physician, nurse practitioner, physician assistant, certified nurse midwife, dentist, mental health professional, or substance use disorder provider). Certification is valid up to one year from the provider's signature.

Mandatory sections include patient information, requesting provider information, diagnosis (ICD-10), and provider signature
Only approved provider types may sign the PCS
Certification valid up to one year from signature

Documentation Required

Transport-specific documentation

Include transport-specific details on the PCS: select the mode of transportation (ambulance types, litter/gurney, wheelchair van, air transport) and provide supporting measurements when bariatric equipment is required (height and weight). For Specialty Care Transport, document clinical needs such as ventilator, respiratory therapist, deep suctioning, or continuous IV medication. For air transport, include the written order and statements justifying why ground transport is inappropriate or infeasible.

Mode selection must be checked (e.g., A0428, A0426, A0434, T2005, A0130, A0430/A0431)
Bariatric measurements required when requesting bariatric litter or wheelchair (height and weight)
Document clinical rationale for Specialty Care Transport and air transport

Denial Risk

Denial triggers

Missing information, unsigned PCS forms, blank mandatory sections, or deficiencies in the PCS may result in denial of the request. Incomplete or illegible documentation and provider signatures from non-approved provider types are common denial triggers.

Unsigned PCS or missing provider signature
Blank or incomplete mandatory sections (marked with '*')
Illegible or missing mode selection or required measurements
Provider not an approved signer

Definitions of Transport Modes

Wheelchair van — definition and coverage conditions

DefinitionWheelchair van: transport when patient is incapable of sitting in a private vehicle, taxi, or public transportation for the required transport time and requires transport in a wheelchair or assistance to/from residence, vehicle, and place of treatment due to a disabling physical or mental limitation.

Special equipmentRequires specialized safety equipment beyond that normally available in passenger cars, taxicabs, or other public conveyances.

Exclusion (ambulance-level services)Not covered if patient requires specialized ambulance services, equipment, or personnel (i.e., patient is unstable or needs constant observation).

LEA exceptionLocal educational agency (LEA) specialized medical transportation services are not subject to the requirement that the patient be transported in a wheelchair or assisted to/from residence, vehicle, and place of treatment.

Litter/Gurney (Stretcher) van — definition and coverage conditions

DefinitionLitter/Gurney (Stretcher) van: transport when the patient must be transported in a prone or supine position because they are incapable of sitting for the required transport time.

Special equipmentRequires specialized safety equipment beyond that normally available in passenger cars, taxicabs, or other public conveyances.

Exclusion (ambulance-level services)Not covered if the patient requires the specialized services, equipment, and personnel provided in an ambulance because the patient is unstable or needs constant observation.

LEA exceptionLocal educational agency (LEA) specialized medical transportation services are not subject to the requirement regarding inability to sit for the transport period.

Ambulance levels (BLS/ALS/SCT) — brief definitions

Basic Life Support (BLS)Includes transfers between facilities for members who require continuous IV medication, medical monitoring or observation; transfers from acute care to another acute care facility; recent initiation of oxygen (excluding chronic portable oxygen users); chronic conditions needing >5L oxygen if monitoring required; and transport from hospital to psychiatric facility.

Advanced Life Support (ALS)Transport from hospital to hospital requiring cardiac monitoring.

Specialty Care Transport (SCT)Transports requiring ventilator support, respiratory therapist, deep suctioning, or continuous IV medication where skilled personnel or specialized equipment are needed during transport (applies to hospital-to-hospital, hospital-to-SNF/residence, or appointment transports as specified).

OpenPayer

Non-Emergency Medical Transportation (NEMT) Request / Physician Certification Statement

Coverage Criteria for NEMT

Provider Actions, Documentation & Authorization

Billing and Diagnosis Codes

Definitions of Transport Modes

Background

A0428	Basic Life Support (ambulance)
A0426	Advanced Life Support (ambulance)
A0434	Specialty Care Transport
T2005	Litter/gurney van
A0130	Wheelchair van
A0430	Air transport
A0431	Air transport