CurrentmhnPolicy N/A

Non-Emergency Medical Transportation (NEMT) Request — Coverage Criteria

Governance of provider requirements and medical necessity criteria for requesting Non-Emergency Medical Transportation (NEMT) services for Medi-Cal managed care members; applies to providers submitting Physician Certification Statements to Health Net for members in North Carolina.

Policy Summary

Payermhn

PolicyNon-Emergency Medical Transportation (NEMT) Request — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed, signed Physician Certification Statement (PCS) via fax to Health Net Care Ride Unit at 833-701-0051 with required patient, provider, and clinical details.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1 yrPCS validity

833-701-0051PCS fax

7 listedTransport codes

60-365dDuration options

Coverage Criteria for NEMT

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Wheelchair van criteria: (A) Patient is incapable of sitting in a private vehicle, taxi, or other public transportation for the duration needed for transport; (B) 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 excluded from this subsection); (C) Requires specialized safety equipment beyond that normally available in passenger cars, taxicabs, or other public conveyances; (D) Does not require ambulance-level specialized services, equipment or personnel because the patient is stable and does not need constant observation.

Document clinical need on the PCS and supporting clinical notes.

inv-02: Gurney/Stretcher van coverage

Gurney/Stretcher (litter) van services are covered when ALL of the following are met:

Gurney/litter van criteria: (A) Patient requires transport in a prone or supine position because the patient is incapable of sitting for the duration needed for transport (LEA specialized medical transportation services are excluded from this subsection); (B) Requires specialized safety equipment beyond that normally available in passenger cars, taxicabs, or other public conveyances; (C) Does not require ambulance-level specialized services, equipment or personnel because the patient is stable and does not need constant observation.

Document clinical need on the PCS and supporting clinical notes.

inv-03: Ambulance coverage (BLS, ALS, SCT)

Ambulance services are covered when the appropriate level matches the member's clinical needs:

Basic Life Support (BLS): Transfers between facilities for members who require continuous intravenous medication, medical monitoring, or observation; transfers from an acute care facility to another acute care facility; transport for members recently placed on oxygen (excludes chronic users who carry their own oxygen); transport for members with chronic conditions who require >5L oxygen when monitoring is required; transport from hospital to psychiatric facility.

Select BLS on the PCS when any listed condition applies.

Advanced Life Support (ALS): Transport from hospital to hospital when cardiac monitoring is required.

Select ALS on the PCS when cardiac monitoring is required.

Specialty Care Transport (SCT): When members require ventilator support, respiratory therapist intervention, deep suctioning, or continuous intravenous medication during transport (hospital-to-hospital, to SNF/residence, or to appointments), select SCT.

Select SCT on the PCS when continuous specialty life support or therapy is required.

inv-04: Air transport coverage

Air transport is covered only when the following are met (emergency or nonemergency conditions):

Emergency air transport: Covered only when medically necessary as demonstrated by compliance with paragraph (b)(1) and when either: (1) the patient's medical condition precludes other means of medical transportation as indicated in the required statement, or (2) the patient or the nearest capable hospital is inaccessible to ground medical transportation as indicated in the required statement.Written statement demonstrating why ground transport is not possible required.

Emergency air transport requires clinical documentation per policy.

Nonemergency air transport: Covered when air transport is necessary due to the patient's medical condition or practical considerations that render ground transportation infeasible; necessity must be substantiated by the content of a written order from a physician, podiatrist, or dentist.Written order/documentation required.

Air transport (A0430/A0431) requires prior authorization and supporting clinical documentation.

Requests for Non-Medical Transportation (NMT)—such as private car or public transportation—do not require submission of the Physician Certification Statement (PCS). Members seeking NMT should be directed to contact Health Net Customer Service (select the Transportation option) rather than submitting the PCS. The PCS requirement applies only to NEMT requests processed through the Care Ride Unit (fax: 833-701-0051), and the PCS is valid for up to 1 year from the provider's signature.

Transportation level must match the member’s documented clinical needs for the specific modality requested. Requests that do not meet the modality-specific medical necessity criteria—for example, requesting ambulance-level transport when the patient is stable and does not need constant observation—are considered not medically necessary and will not be covered. Wheelchair van, gurney/litter van, and ambulance (BLS/ALS/SCT) each have distinct, required criteria (e.g., inability to sit for wheelchair or litter indications; continuous IV, monitoring or ventilator needs for ambulance) that must be documented on the PCS and supporting clinical notes.

Provider Actions and Requirements

Prior Authorization

Select and document transport mode on PCS

Provider must select the appropriate transport mode on the Physician Certification Statement (PCS) and include required details such as bariatric height/weight when applicable. Air transport selections on the PCS require prior authorization through Health Net and must be supported by clinical documentation demonstrating medical necessity (see air transport criteria).

Select one transport mode on PCS: Ambulance (BLS A0428, ALS A0426, Specialty A0434, Litter/gurney T2005), Wheelchair van (A0130), or Air transport (A0430/A0431).
If bariatric equipment is needed, include member height and weight on the PCS.
Air transport requires prior authorization and must meet clinical documentation criteria for emergency or non‑emergency air transport.

Documentation Required

Completed PCS signed by an approved provider required

A completed Physician Certification Statement (PCS), signed by an approved provider (physician, nurse practitioner, physician assistant, certified nurse midwife, dentist, mental health professional, or substance use disorder provider), must be submitted to Health Net to request NEMT services. The certification is valid for up to one year from the provider signature.

Fax the completed, signed PCS to Health Net Care Ride Unit: 833-701-0051.
Ensure all mandatory fields (marked with '*') are completed before submission.

Denial Risk

No changes allowed after PCS submission

No changes can be made by Health Net or the transportation vendor after the PCS has been submitted by the approved provider. Any change requires a new, completed PCS form submitted by the physician or other authorized provider.

Once submitted, neither Health Net nor the transportation vendor may modify the request without a new PCS from the provider.
Providers must submit a new PCS for any change to transport mode, dates, or clinical information.

Definitions and Service Types

inv-14: Wheelchair van — definition/key attributes

DefinitionWheelchair van: transport for patients who are incapable of sitting in a private vehicle, taxi, or public transportation for the time needed and require transport in a wheelchair or assistance to/from residence, vehicle and place of treatment due to a disabling physical or mental limitation.

Equipment/needsRequires specialized safety equipment beyond that normally available in passenger cars, taxicabs, or public conveyance.

Exclusion vs ambulancePatient must NOT require ambulance-level specialized services, equipment, or personnel (patient is stable and does not need constant observation).

LEA exceptionLocal Educational Agency (LEA) specialized medical transportation services are not subject to the requirement that the patient require assistance to/from residence, vehicle and place of treatment (subsection (B)1).

inv-15: Litter/gurney van — definition/key attributes

DefinitionGurney/Stretcher (litter) van: transport for patients who require prone or supine positioning because they are incapable of sitting for the time needed to transport.

Equipment/needsRequires specialized safety equipment beyond that normally available in passenger cars, taxicabs, or public conveyance.

Exclusion vs ambulancePatient must NOT require the specialized services, equipment, and personnel provided in an ambulance (patient is stable and does not need constant observation).

LEA exceptionLocal Educational Agency (LEA) specialized medical transportation services are not subject to the prone/supine requirement in subsection (A)1.

inv-16: Ambulance levels — BLS, ALS, SCT definitions

Basic Life Support (BLS)Use BLS for transfers requiring continuous IV medication, medical monitoring or observation; transfers between acute care facilities; recent initiations of oxygen (excluding chronic users who carry own oxygen); chronic conditions needing >5L oxygen if monitoring required; hospital-to-psychiatric facility transfers.

Advanced Life Support (ALS)Use ALS for hospital-to-hospital transports that require cardiac monitoring.

Specialty Care Transport (SCT)Use SCT when patient requires ventilator support, respiratory therapist, deep suctioning, or continuous IV medication during transport (includes hospital-to-hospital, hospital-to-SNF/residence, or to appointments).

inv-17: Air transport — reserved situations and documentation requirement

Reserved situations (emergency)Air transport for emergencies is covered only when medically necessary per paragraph (b)(1) and when the patient’s condition precludes other means of transport or the patient/nearest capable hospital is inaccessible to ground transport, as documented in the required statement.

Reserved situations (nonemergency)Nonemergency air transport is covered when ground transport is not feasible due to the patient’s medical condition or practical considerations; necessity must be substantiated by a written order of a physician, podiatrist, or dentist.

Documentation requirementClinical documentation and the written statement/order demonstrating why ground transport is contraindicated or infeasible are required to support air transport coverage.

Background

Medi‑Cal managed care plans are required to provide Non‑Emergency Medical Transportation (NEMT) for members who cannot reasonably ambulate or who are unable to stand or walk without assistance (including those using a walker or crutches). The appropriate level of transportation is determined by the member’s medical and physical condition and must be certified using the PCS signed by an approved provider.