Non-Emergent Medical Transportation (NEMT) Billing Manual

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Benefit Overview

Non-emergent medical transportation (NEMT) is transportation to and from medically necessary services covered by Health First Colorado (Colorado's Medicaid Program) for members who have no other means of transportation, including free transportation. NEMT can only be utilized to access non-emergency services.

NEMT can only be utilized to transport eligible members to and from Health First Colorado provider service locations that are enrolled to provide the service the member is transported to receive. To determine if a provider or service location is an approved Health First Colorado provider, visit the Department's website and select the Find a Doctor tool. NEMT must be used to access the closest qualified Health First Colorado provider willing and able to treat the member. NEMT can only be used to access non-emergency services. Transportation to receive Home and Community Based Services (HCBS) must be provided through Non-Medical Transportation (NMT).

Providers must be enrolled as a Health First Colorado provider in order to:

  • Provide NEMT services to a Health First Colorado member
  • Submit claims for payment to Health First Colorado

Providers should refer to the Code of Colorado Regulations (CCR), Program Rules (10 CCR 2505-10), for specific information when providing NEMT services.

NEMT Regulations can be found in 10 CCR 2505-10 8.014.

Emergency Medical Transportation (EMT) regulations allow inter-facility transfers between hospitals to be billed as EMT services. These transfers can include transportation of people who are experiencing a mental health or substance use disorder crisis. The Department clarified this in the October 2017 Provider Bulletin.

Any services provided by Transportation Network Companies, as defined in 4 CCR 723-6701 (e.g., Uber, Lyft), are not covered or reimbursed under NEMT. Ride-sharing companies are not enrolled providers and the Department is unable to pay for or reimburse for use of these services.

An exception may be made, at the Department’s discretion, for covered Out-of-State trips. The Department does not maintain a network of providers outside the State of Colorado and therefore may provide reimbursement for Members who have an approved NEMT Out-of-State trip.

9-1-1 response calls are not NEMT. If transportation is provided to the member in response to a 9-1-1 call, and the service meets the requirements of EMT, the service may be billed as EMT services.

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General Billing Information

Refer to the General Provider Information manual for general billing information.

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NEMT Administration

The Department has established a State Designated Entity (SDE) responsible for administering NEMT throughout Colorado. The SDE explores and utilizes the least costly, medically-appropriate means of transportation for each member and arranges those transportation services.

Colorado has one State Designated Entity, IntelliRide, the Department’s contracted NEMT broker.


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Eligible Providers

To provide NEMT services to Health First Colorado members and receive reimbursement, a provider must:

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Ambulance Providers

Ambulance providers must complete a separate enrollment application to be eligible to provide Emergency Medical Transportation services.

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HCBS Non-Medical Transportation (NMT) Providers

To provide Non-Medical Transportation (NMT) services, a separate enrollment application is necessary to submit claims for NMT services. A provider cannot bill NMT services through their NEMT Provider ID.

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Exceptions

The only exceptions to these provider requirements are reimbursements or mileage paid to members, members' family, members' friends, or volunteers for covered services; and commercial air, train, and bus tickets. Lodging providers are not required to obtain PUC or ambulance licensure but must enroll as a Health First Colorado NEMT provider in order to submit claims for services.

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Payment for Covered Services

Payment will only be made for the least expensive mode suitable to the member's condition.

Providers in the state-contracted broker service area must be enrolled in the broker's network in order to provide services and receive payment for covered services. The broker pays enrolled providers directly for NEMT services. Services provided in the broker service area are only reimbursable by the State Contracted Broker and cannot be submitted directly to the Department.

Regardless of whether Health First Colorado has actually reimbursed the provider, billing members for covered services is strictly prohibited. Balance billing is prohibited. If reimbursement is made, providers must accept this payment as payment in full (see Program Rule 8.012). The provider may only bill the member for services not covered by Health First Colorado.

For detailed coverage and service limitations, please refer to the Non-Emergent Medical Transportation Benefit Coverage Standard on the Department's website.

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Member Eligibility

To receive NEMT, a person must:

  • Be a current Health First Colorado member, receiving Medicaid State Plan / Title XIX coverage on the date of service;
  • Not have access to other means of transportation including free transportation and the Program of All-Inclusive Care for the Elderly (PACE);
  • Require transportation to obtain non-emergency Health First Colorado covered medical services at Health First Colorado enrolled providers; and
  • Not be within the following eligibility groups:
    • Qualified Medicaid Beneficiary (QMB) Only
    • Special Low-Income Medicare Beneficiary (SLMB) Only
    • Medicare Qualifying Individual-1 (QI-1)
    • Old Age Pension- State Only (OAP-state only)
    Note: CHP+ is not Health First Colorado and, therefore, is not eligible for NEMT services.

Web Portal example of a member eligible for NEMT services:

Member eligible for NEMT

If the member has only QMB coverage without the "Medicaid state plan", the member is not eligible for NEMT services.

QMB-only member

Prior Authorization

All NEMT requests must be sent to the State Designated Entity (SDE). The member, or member's representative, is responsible for obtaining prior authorization and should be requested as soon as possible. Transportation provided without authorization from the SDE, or their designee, will not be reimbursed or paid. For information on the SDE's authorization process, contact the SDE directly.

While not requiring prior authorization, mileage or bus pass reimbursement may be denied if the member does not provide proper documentation to the State Designated Entity within timely filing requirements, or sooner if required by the State Designated Entity's policies.

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Train, Air, and Out-of-State Travel

Train, air, and out-of-state travel must be prior authorized by the Department. Members and/or medical professionals requesting train, air, or out-of-state travel must contact their SDE.

NEMT can only be used to access approved medical services. 10 CCR 2505-10 8.013 requires all medical services to be provided in Colorado, unless the service is not available in-state.

The SDE will request the required documentation and submit to the Department for review and decision. The decision will be communicated to the SDE.

SDEs must submit a completed NEMT Air, Train, and Out-of-State Request Form as indicated on the form. The form is available on the NEMT section of the Department's website.

All rules and practices for in-state NEMT apply to travel for routine medical services provided to members in Colorado border communities performed across the state line in a Border Town/City indicated in Appendix F because of closer proximity to the closest qualified provider. Appendix F is available under the Appendices drop-down section on the Billing Manuals web page.

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Covered Benefits and Limitations

Non-Emergent Medical transportation (NEMT) is a Health First Colorado benefit when the member has no other means of transportation. The transportation services must be medically necessary and provided within the scope of the provider's certification and/or license. Transportation for Health First Colorado members to and from a medical provider is a benefit when the medical service provided is a benefit of the Health First Colorado and the provider is enrolled with Health First Colorado to deliver the service.

There is no limit to the number of daily trips a client can receive from one or multiple providers, but those trips must meet all NEMT regulatory and policy requirements. Billing multiple trips for one member in one day with different rendering providers may require the use of a modifier (see Procedure Coding, below).

The following modes of transportation are covered:

  • Public/Mass Transportation
  • Personal vehicle mileage reimbursement
  • Mobility/Ambulatory vehicles
  • Wheelchair van
  • Taxicab
  • Stretcher van
  • Ambulance, ground and air
  • Commercial plane
  • Train

Ancillary services may also be covered. Ancillary services include:

  • Escort transportation
  • Lodging
  • Meals
  • Escort's lodging
  • Escort's meals

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Types of Non-Emergent Medical Transportation

Public/Mass Transportation
Public/mass transportation, including fixed route, light rail, paratransit, and private bus transportation, may be available when these modes of transportation are the least costly and most appropriate to the member's condition. Transit passes may be issued when the cumulative cost of bus trips exceeds the cost of a pass.

Procedure Code(s): A0110

Personal Vehicle Mileage Reimbursement
A private vehicle may be provided by a volunteer, (individual or organization, with no member vested interest) or a vehicle provided by an individual, (family member, self, neighbor), with a member vested interest.

Mileage reimbursement for a personal vehicle is reimbursed per vehicle, without regard to the number of members or escorts in the vehicle and is only reimbursed using the most direct route to and from the appointment. Exceptions can be made by the SDE if the shortest distance is impassable due to severe weather, road closure, or other unforeseen circumstances outside of the member's control that severely limit using the shortest route. If an exception is made, the SDE must document the reason and can pay mileage for the actual route traveled.

Procedure Code(s): A0080, A0090

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Mobility/Ambulatory Vehicles
Mobility/Ambulatory vehicle services are transportation services provided to individuals who are not wheelchair confined. A mobility/ambulatory vehicle is a passenger carrying vehicle for hire, including those designed, constructed, modified or equipped to meet the needs of passengers with medical, physical or mobility impairments and, when medically necessary, their certified escorts. Mobility/ambulatory vehicle providers must have, and maintain one of the following PUC licenses, or be determined exempt by PUC statutes:

  • Contract Carrier permit
  • Medicaid Client Transport (MCT) permit
  • Luxury Limousine

Providers must provide services in compliance with PUC licensure and state and federal laws.

Taxi service is not a mobility vehicle; however, a taxi company may also have an MCT permit or luxury limousine authority from the PUC and may operate its vehicles under that authority as mobility/ambulatory vehicles.

In this case, the taxi company agrees to the Health First Colorado reimbursement for mobility /ambulatory vehicles. A mobility vehicle may submit claims using wheelchair van procedure codes only when the member is a wheelchair user and the vehicle has been modified with appropriate wheelchair equipment. If these requirements are not met, the mobility/ambulatory vehicle may not bill using wheelchair van codes. (See Wheelchair Van)

Mobility/ambulatory vehicle transportation is a Health First Colorado benefit when the member's medical or physical condition precludes the use of member-purchased public or private transportation, or other less costly modes of Health First Colorado transportation. The SDE is responsible for ensuring documentation from the member's medical professional indicates, in writing, the member is unable to use less costly modes of NEMT services (e.g., mileage reimbursement, bus tickets).

Mileage shall be paid for the shortest trip length in miles as determined by an internet-based map, trip planner, or other Global Positioning System (GPS).

Procedure Code(s): A0120, A0425

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Wheelchair Van
A wheelchair van is a vehicle for hire that has been specifically designed, constructed, modified, or equipped to accommodate the needs of wheelchair users. Wheelchair van services are a Health First Colorado benefit only when the member's medical professional indicates, in writing, the member is wheelchair-confined and unable to use less costly modes of NEMT services (e.g., mileage reimbursement, bus tickets).

Wheelchair van providers must have, and maintain one of the following PUC licenses, or be determined exempt by PUC statutes:

  • Contract Carrier permit
  • Medicaid Client Transport (MCT) permit

Providers must provide services in compliance with PUC licensure and state and federal laws.

When operating as a wheelchair van, the provider agrees to wheelchair van reimbursement.

Wheelchair vans must bill using mobility/ambulatory vehicle procedure codes if the member's medical professional has not indicated in writing that the member is wheelchair-confined. In this case, the mobility /ambulatory vehicle must also meet PUC requirements for mobility vehicle services and agrees to the Health First Colorado reimbursement for mobility/ambulatory vehicles. (See Mobility/Ambulatory Vehicle)

Mileage shall be paid for the shortest trip length in miles as determined by an internet-based map, trip planner, or other Global Positioning System (GPS).

Procedure Code(s): A0130, S0209

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Taxicab
A taxicab service means passenger transportation by a common carrier on a call-and-demand basis in a taxicab, with the first passenger therein having exclusive use of the taxicab unless such passenger agrees to multiple loading. Taxicab providers must have and maintain a common carrier certificate with authority to provide taxicab service. Providers must provide services in compliance with PUC licensure and state and federal laws.

Taxicab services are a Health First Colorado benefit when the member's medical or physical condition precludes the use of member-purchased public or private transportation, or other less costly modes of Health First Colorado transportation. The SDE is responsible for ensuring documentation from the member's medical professional indicates, in writing, the member is unable to use less costly modes of NEMT services (e.g., mileage reimbursement, bus tickets). Mileage shall be paid for the shortest trip length in miles as determined by an internet-based map, trip planner, or other Global Positioning System (GPS).

Taxicab service is not a mobility vehicle; however, a taxi company may also have an MCT permit or luxury limousine authority from the PUC and may operate its vehicles under that authority as mobility / ambulatory vehicles. In this case, the taxi company agrees to the Health First Colorado reimbursement for mobility /ambulatory vehicles. (See Mobility/Ambulatory Vehicles)

Procedure Code(s): A0100

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Stretcher Van
Stretcher van is a vehicle that can legally transport a client in a prone or supine position when the client does not require medical attention en route. This may be by stretcher, board, gurney, or other appropriate device. Medical or safety requirements must be the basis for transporting a client in the prone or supine position.

Stretcher van service is a Health First Colorado benefit when the member's medical professional indicates, in writing, the member must be transported in a prone or supine position and they are unable to use less costly modes of NEMT services (e.g., mileage reimbursement, bus tickets).

Mileage shall be paid for the shortest trip length in miles as determined by an internet-based map, trip planner, or other Global Positioning System (GPS).

Procedure Code(s): T2005, T2049

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Ground Ambulance
Ambulance means any publicly or privately-owned vehicle that is specially designed, constructed, modified or equipped to be used, maintained and operated on streets or highways to transport clients to a hospital or other treatment facility in cases of accident, trauma or severe illness. Transport of clients requiring cardiac/hemodynamic monitoring is considered to be non-emergency only if such monitoring is required both before and after transport. Advanced airway management shall include clients who are ventilator dependent, require intubation and/or deep suctioning en route, or are on an apnea monitor before, during and after transport. Administration of intravenous (IV) medication en route shall not include self-administered IV medications.

Non-emergent ground ambulance service is a Health First Colorado service when the member's medical professional indicates that the member requires an ambulance in order to be transported safely and they are unable to use less costly modes of NEMT services (e.g., mileage reimbursement, bus tickets). All out-of-state ground ambulance trips must be prior approved by the Department (See Prior Authorization).

Procedure Code(s): A0428, A0426, A0433, A0434, A0425, A0021, A0422

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Air Ambulance
Air ambulance means a fixed wing or rotor wing aircraft that is equipped to provide air transportation and is specifically designed to accommodate the medical needs of individuals who are ill, injured, or otherwise mentally or physically incapacitated and who require in-flight medical supervision.

Non-emergent air ambulance benefits are provided when:

  • Non-emergent, pre-planned services are authorized by the State authorizing agency.
  • Great distances or other obstacles prohibit transporting the member by land to the nearest appropriate facility and the member's condition requires immediate attention.
  • The member is suffering from an illness or injury making other forms of transportation inadvisable.

Non-emergent air ambulance service is a Health First Colorado service when the member's medical professional indicates, in writing, that the member requires air ambulance in order to be transported safely and they are unable to use less costly modes of NEMT services. All NEMT air ambulance trips must be prior approved by the Department (See Prior Authorization).

Procedure Code(s): A0430, A0431

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Commercial Air
Commercial air means travel via an airline which provides scheduled air transportation for passengers.

Commercial air transport is a Health First Colorado service when the member's medical professional indicates that the member requires commercial air in order to be transported safely and they are unable to use less costly modes of NEMT services. All NEMT commercial air trips must be prior approved by the Department (See Prior Authorization).

Procedure Code(s): A0140

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Train
Train means passenger-carrying railroad cars.

Train transport is a Health First Colorado service when the member's medical professional indicates that the member requires train transportation in order to be transported safely and they are unable to use less costly modes of NEMT services. All NEMT train trips must be prior approved by the Department (See Prior Authorization).

Procedure Code(s): A0140

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Ancillary Services

Escort
An escort may accompany a member when:

  • The member is a child or an at-risk adult, and is unable to make personal/medical determinations or provide necessary self-care as certified in writing by the member's attending Medicaid enrolled provider.
  • The escort or attendant must be physically and cognitively capable of providing the needed services for the member.

NEMT may cover the cost of transporting a second escort with written certification for medical necessity from the member's medical provider, if:<

  • The member has a behavioral or medical condition which may cause the member to be a threat to self or others if only one escort is provided, or
  • The member's primary caretaker has a disability that precludes the caregiver from providing all of the member's needs during transport or extended stay.

Minors who are at least thirteen (13) years old, but younger than eighteen (18) years old, may travel alone with a written release from their parent or guardian, as long as an adult is present to receive the minor at the destination and at the return location. Minors under thirteen (13) years old shall not travel without an escort.

Children in a day treatment program may travel without an escort, as long as there is a written release from their parent or guardian, stating that an adult will be present to receive the minor at the destination and return location. Children are not eligible for NEMT travel to and from school funded day treatment programs.

Procedure Code(s): T2001

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Meals/Lodging:
Meals and lodging for members are available for:

  • In-state treatment when travel cannot be completed in one calendar day
  • Authorized out-of-state treatment if meals or lodging is not included as part of an inpatient stay.

Meals and lodging may be covered for the escort when a member is a child or an at-risk adult who requires the escort's continued stay.

Reimbursement will only be made for meals and lodging that members and escorts are actually charged for, up to the daily per diem rate established by the Department. If a member is not normally billed for meals and lodging will not be reimbursed.

Meals and lodging are limited to one unit per day each, per member or escort.

Procedure Code(s): A0180, A0190, A0200, A0210

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Urgent NEMT

Effective January 1, 2019, eligible transportation providers can provide urgent Non-Emergent Medical Transportation (NEMT) trips scheduled directly by Medical Facilities. This is a change to current processes where facilities and transportation vendors work with the State Designated Entity.

Urgent NEMT is transportation needed to receive necessary medical services when a member is unable to provide advanced notice. This includes:

  • Transportation after discharge from a hospital
  • Failure of an NEMT provider to pick up a member from an appointment within one hour of the scheduled pick up time
  • Transportation to and from critical, unplanned medical appointments.

Transportation will still only be provided to and from services that are covered under Health First Colorado (Colorado's Medicaid Program) and meet the requirements for NEMT services. Non-urgent NEMT will continue to follow the same process required by the NEMT State Designated Entity.

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Exclusions

The following services are not Health First Colorado NEMT benefits:

  • Services provided only as a convenience to the member as opposed to medical necessity.
  • Charges incurred while the member is not in the vehicle, except for lodging and meals.
  • Transportation to/from non-covered medical services, including services that do not qualify due to coverage limitations.
  • Waiting time.
  • Cancellations.
  • Transportation which is covered by another entity (e.g., transportation provided by the Veterans Administration or a school).
  • Metered taxi services.
  • Charges for additional passengers except when acting as an escort for a child or at-risk adult.
  • Response calls when, upon arrival at the site of the call, no transportation is needed or provided.
  • Transportation for nursing facility or group home residents to medical or rehabilitative services required in the facility's program, unless the facility does not have an available vehicle. Nursing facilities and group homes should instead report transportation as part of their allowable costs on their state-approved cost report.

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Resources

Code of Federal Regulations (CFR)

Title 42 CFR, §431.53 requires states to:

  • Ensure transportation for members to and from providers, and
  • Specify in the Medicaid State Plan, which must be approved by the Centers for Medicare and Medicaid Services (CMS), the methods the state will use to ensure transportation.

Please visit the Electronic Code of Federal Regulations website for more information.

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Colorado's Medicaid State Plan

Colorado's Medicaid State Plan is the contract with CMS outlining how Colorado will run the Medicaid program. Attachment 3.1.-D, Methods of Assuring Transportation covers NEMT and specifies the methods used to ensure transportation for members, as required by 42 CFR, §431.53. Colorado's Medicaid State Plan website

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Colorado Code of Regulations (CCR)

The Colorado Code of Regulations are the state's rules governing programs and services. 10 CCR 2505-10.8.014 covers NEMT.

To find the current version of 10 CCR 2050-10 8.000 (which includes 8.014), visit the Code of Colorado Regulations web page.

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Benefit Coverage Standard

The NEMT Benefits Collaborative Policy Statement (also known as the Benefit Coverage Standard) is the detailed policy on the program.

Visit the Benefit Coverage Standards web page (find Non-Emergent Medical Transportation Services).

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Rate & Fee Schedule

The Provider Rate & Fee Schedule outlines the current NEMT rates and available procedure codes. The Rate & Fee Schedule is updated annually around July 1 with the new rates implemented by the legislature for the new State Fiscal Year.

Visit the Provider Rates & Fee Schedules web page (NEMT is located under Transportation Rate Schedule).

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HCPF NEMT Web Page

The Department's NEMT web page is a brief overview of NEMT and includes some resources.

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Find a Doctor Tool

NEMT must be used to access the closest qualified provider of that services. There is an online tool to find the closest provider, accessible on the Department's website by clicking Find Doctors.

Provider Contacts

Provider contacts can be found on the Provider Contacts web page.

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Procedure Coding

Health First Colorado uses the Centers for Medicare & Medicaid Services (CMS) Healthcare Common Procedural Coding System (HCPCS). The codes are used for submitting claims for services provided to Health First Colorado members and represent services that may be provided by enrolled, certified Health First Colorado providers.

HCPCS are used to identify and reimburse non-emergent medical transportation services.

The Department updates and revises HCPCS codes through Health First Colorado billing manuals.

The series of local procedure codes used to bill for mobility van services (X6022-X6030) are no longer available. Providers should use HCPCS A0120 plus modifier TK (Extra member or passenger) to bill for mobility van services. Use the appropriate number of units to identify the actual number of riders.

When billing for one member taking multiple trips in the same day with different rendering providers, modifier 77 must be used.

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Public/Mass Transportation

Procedure Code Mod-1 Mod-2 Mod-3 Unit Description
A0110 TN     Ticket, One-Way Fixed Route, One-Way, Local
A0110 SC SE TN Ticket, One-Way Fixed Route, One-Way, Regional
A0110 SE     Ticket, One-Way Paratransit, One-Way
A0110       Ticket, One-Way Public/Mass Transportation; Bus Service

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Personal Vehicle Mileage Reimbursement

Code Unit Description
A0080 Mile Volunteer Vehicle Mileage - vehicle provided by volunteer (individual or organization), with no vested interest
A0090 Mile Individual Vehicle Mileage - vehicle provided by individual (family member, self, neighbor) with vested interest

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Mobility / Ambulatory Vehicles

Code Unit Description
A0120 One Way Trip Mobility / Ambulatory Vehicles
A0425 Mile Ground mileage, per statute mile

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Wheelchair Van

Code Unit Description
A0130 One Way Trip Wheelchair Van
S0209 Mile Wheelchair Van Mileage

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Taxicab

Code Unit Description
A0100 One Way Trip Taxi

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Stretcher Van

Code Unit Description
T2005 One Way Trip Stretcher van
T2049 Mile Stretcher Van Mileage

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Ground Ambulance

Code Unit Description
A0428 One Way Trip Nonemergency transportation: Ambulance service- Basic Life Support (BLS)
A0426 One Way Trip Nonemergency transportation: Ambulance service- Advanced Life Support (ALS), level 1
A0433 One Way Trip Ambulance service- Advanced Life Support (ALS), level 2
A0434 One Way Trip Specialty care transport (SCT)
A0425 Mile Ground mileage, per statute mile
A0021 Mile Ambulance service, outside state per mile, transport
A0422 Per Unit Ambulance (ALS or BLS) oxygen and oxygen supplies, life sustaining situation

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Air Ambulance

Code Unit Description
A0430 One Way Trip Ambulance service, conventional air services, transport, one way (fixed wing)
A0431 One Way Trip Ambulance service, conventional air services, transport, one way (rotary wing)

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Commercial Air and Train

Code Unit Description
A0140 Per Trip Train and/or Air

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Ancillary Services

Code Unit Unit Limit Description
T2001 One Way Trip N/A Escort Transportation
A0180 Per Diem 1 per day Travel Lodging for Member
A0190 Per Diem 1 per day Travel Meals for Member
A0200 Per Diem 1 per day, per escort Travel Lodging for Escort
A0210 Per Diem 1 per day, per escort Travel Meals for Escort

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NEMT Billing Information

The 837 Professional (837P) transaction should be utilized for electronic billing.

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Claim Type

NEMT Claims submitted via the web portal are Professional Claims.

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Diagnosis Codes

A diagnosis is required on all claims. Enter code R68.89 for all claims. Do not fill unused spaces with zeroes. The diagnosis must be referenced to each detail line by placing a "1" in the diagnosis indicator field.

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Dates of Services

Each detail line includes space to enter two (2) dates of service: a 'From' Date Of Service (FDOS) and a 'To' Date Of Service (TDOS). Both dates must be completed on the electronic record. For services rendered on a single date, complete the FDOS and the TDOS with the same date.

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Span Billing

Span billing is not allowed for transportation services.

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Place of Service Codes

Use CMS place of service codes. Use place of service codes:

  • 41-land transportation
  • 42-air transportation

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Procedure Codes

Each detail line must include a valid NEMT procedure code.

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EMG (Emergency) Indicator

The Emergency Indicator is used to differentiate some NEMT services from Emergency Medical Transportation. Enter N or leave blank to indicate the service was non-emergency medical transportation.

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Transportation Certification

Transportation Certification is optional for NEMT claims.

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Attachments

Beginning 3/1/17, attachments can be submitted with electronic claims submitted via the web portal. NEMT claims which require manual pricing must include an attachment that supports the claim.

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CMS 1500 Paper Claim Reference Table

The following paper form reference table shows required, optional, and conditional fields and detailed field completion instructions for the EPSDT claim form.

 

CMS Field Number & Label Field is? Instructions
1. Insurance Type Required Place an "X" in the box marked as Medicaid.
1a. Insured's ID Number Required Enter the member's Health First Colorado seven-digit Medicaid ID number as it appears on the Health First Colorado Identification card. Example: A123456.
2. Patient's Name Required Enter the member's last name, first name, and middle initial.
3. Patient's Date of Birth/Sex Required Enter the member's birth date using two digits for the month, two digits for the date, and two digits for the year. Example: 070114 for July 1, 2014.

Place an "X" in the appropriate box to indicate the sex of the member.
4. Insured's Name Conditional Complete if the member is covered by a Medicare health insurance policy.

Enter the insured’s full last name, first name, and middle initial. If the insured used a last name suffix (e.g., Jr, Sr), enter it after the last name and before the first name.
5. Patient's Address Not Required  
6. Client Relationship to Insured Conditional Complete if the member is covered by a commercial health care insurance policy.
7. Insured's Address Not Required  
8. Reserved for NUCC Use Not Required  
9. Other Insured's Name Conditional If field 11d is marked "YES", enter the insured’s last name, first name and middle initial.
9a. Other Insured's Policy or Group Number Conditional If field 11d is marked "YES", enter the policy or group number.
9b. Reserved for NUCC Use    
9c. Reserved for NUCC Use    
9d. Insurance Plan or Program Name Conditional If field 11D is marked "YES", enter the insurance plan or program name.
10a-c. Is patient's condition related to? Conditional When appropriate, place an "X" in the correct box to indicate whether one or more of the services described in field 24 are for a condition or injury that occurred on the job, as a result of an auto accident or other.
10d. Reserved for Local Use    
11. Insured's Policy, Group or FECA Number Conditional  
11a. Insured's Date of Birth, Sex Not Required Complete if the member is covered by a Medicare health insurance policy. Enter the insured’s birth date using two digits for the month, two digits for the date and two digits for the year. Example: 070114 for July 1, 2014.

Place an “X" in the appropriate box to indicate the sex of the insured.
11b. Other Claim ID Not Required  
11c. Insurance Plan Name or Program Name Not Required  
11d. Is there another Health Benefit Plan? Conditional When appropriate, place an "X" in the correct box. If marked "YES", complete 9, 9a and 9d.
12. Patient's or Authorized Person's signature Required Enter "Signature on File", "SOF", or legal signature. If there is no signature on file, leave blank or enter "No Signature on File".

Enter the date the claim form was signed.
13. Insured's or Authorized Person's Signature Not Required  
14. Date of Current Illness Injury or Pregnancy Not Required  
15. Other Date Not Not Required  
16. Date Patient Unable to Work in Current Occupation Not Required  
17. Name of Referring Physician Conditional  
17b. NPI of Referring Physician Conditional  
18. Hospitalization Dates Related to Current Service Not Required  
19. Additional Claim Information Conditional When applicable, enter the words "TRANSPORT CERT" to certify that you have a transportation certificate or trip sheet on file for this service.
20. Outside Lab?
$ Charges
Not Required  
21. Diagnosis or Nature of Illness or Injury Required Enter at least one but no more than twelve diagnosis codes based on the member’s diagnosis/condition.

Enter applicable ICD-10 indicator.
NEMT
Enter diagnosis code R68.89.
22. Medicaid Resubmission Code Conditional List the original reference number for resubmitted claims.

When resubmitting a claim, enter the appropriate bill frequency code in the left- hand side of the field.
7 - Replacement of prior claim
8 - Void/Cancel of prior claim
This field is not intended for use for original claim submissions.
23. Prior Authorization Not Required  
24. Claim Line Detail Information The paper claim form allows entry of up to six detailed billing lines. Fields 24A through 24J apply to each billed line.

Do not enter more than six lines of information on the paper claim. If more than six lines of information are entered, the additional lines will not be entered for processing.

Each claim form must be fully completed (totaled).

Do not file continuation claims (e.g., Page 1 of 2).
24A. Dates of Service Required The field accommodates the entry of two dates: a "From" date of services and a "To" date of service. Enter the date of service using two digits for the month, two digits for the date and two digits for the year. Example: 010116 for January 1, 2016.
From To
01 01 19 01 01 19
Single Date of ServiceEnter the six-digit date of service in the "From" field.
Completion of the “To field is not required. Do not spread the date entry across the two fields.

Span Billing is not allowed for NEMT.
24B. Place of Service Required Enter the Place of Service (POS) code that describes the location where services were rendered. Health First Colorado accepts the CMS place of service codes.
41 Transportation - Land
42 Transportation - Air or Water
24C. EMG Conditional Enter a "N" or leave blank for NO in the bottom, unshaded area of the field to indicate the service was non-emergent medical transportation.
24D. Procedures, Services, or Supplies Required Enter the HCPCS procedure code that specifically describes the service for which payment is requested.

Only approved codes from the current CPT or HCPCS publications will be accepted.
24D. Modifier Not Required Enter the appropriate procedure-related modifier that applies to the billed service. Up to four modifiers may be entered when using the paper claim form.

NEMT
Only A0110 may require a modifier (see Transportation HCPCS codes).
24E. Diagnosis Pointer Required Enter the diagnosis code reference letter (A-L) that relates the date of service and the procedures performed to the primary diagnosis.

At least one diagnosis code reference letter must be entered.

When multiple services are performed, the primary reference letter for each service should be listed first, other applicable services should follow.

This field allows for the entry of 4 characters in the unshaded area.
24F. $ Charges Required Enter the usual and customary charge for the service represented by the procedure code on the detail line. Do not use commas when reporting dollar amounts. Enter 00 in the cents area if the amount is a whole number.

Submitted charges cannot be more than charges made to non-Health First Colorado covered individuals for the same service.

Do not deduct Health First Colorado co- payment or commercial insurance payments from the usual and customary charges.
24G. Days or Units Required Enter the number of units provided for each procedure code.

Enter whole numbers only- do not enter fractions or decimals.
24H. EPSDT/Family Plan Not Required  
24I. ID Qualifier Not Required  
24J. Rendering Provider ID # Required In the shaded portion of the field, enter the NPI or Provider ID of the Health First Colorado provider who actually performed or rendered the billed service. This number cannot be assigned to a group or clinic.
25. Federal Tax ID Number Not Required  
26. Patient's Account Number Optional Enter information that identifies the member or claim in the provider's billing system. Submitted information appears on the Remittance Advice (RA).
27. Accept Assignment? Required The accept assignment indicates that the provider agrees to accept assignment under the terms of the payer’s program.
28. Total Charge Required Enter the sum of all charges listed in field 24F. Do not use commas when reporting dollar amounts. Enter 00 in the cents area if the amount is a whole number.
29. Amount Paid Conditional Enter the total amount paid by Medicare or any other commercial health insurance that has made payment on the billed services.

Do not use commas when reporting dollar amounts. Enter 00 in the cents area if the amount is a whole number.
30. Rsvd for NUCC Use    
31. Signature of Physician or Supplier Including Degrees or Credentials Required Each claim must bear the signature of the enrolled provider or the signature of a registered authorized agent.

Each claim must have the date the enrolled provider or registered authorized agent signed the claim form. Enter the date the claim was signed using two digits for the month, two digits for the date and two digits for the year. Example: 070116 for July 1, 2016.
32. 32- Service Facility Location Information
32a- NPI Number
32b- Other ID #
Required Enter the name, address and ZIP code of the individual or business where the member was seen or service was performed in the following format:
1st Line Name
2nd Line Address
3rd Line City, State and ZIP Code
If the Provider Type is not able to obtain an NPI, enter the eight-digit Health First Colorado provider number of the individual or organization.
33. Billing Provider
Info & Ph #
Required Enter the name of the individual or organization that will receive payment for the billed services in the following format:
1st Line Name
2nd Line Address
3rd Line City, State and ZIP Code
33a- NPI Number Required  
33b- Other ID #   If the Provider Type is not able to obtain an NPI, enter the eight-digit Health First Colorado provider number of the individual or organization.

 

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CMS 1500 Transportation Claim Example

NEMT Claim Example

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Transportation Third Party Claim - No Mileage Example

Transportation Third Party Claim - No Mileage Example

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Timely Filing

For more information on timely filing policy, including the resubmission rules for denied claims, please see the General Provider Information manual.

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NEMT Billing Manual Revisions Log

Revision Date Section/Action Made by
12/1/2016 Manual revised for interChange implementation. For manual revisions prior to 12/01/2016, please refer to Archive. HPE
12/27/2016 Updates based on Colorado iC Stage II Provider Billing Manual Comment Log v0_2.xlsx HPE
1/10/2017 Updates based on Colorado iC Stage Provider Billing Manual Comment Log v0_3.xlsx HPE
1/19/2017 Updates based on Colorado iC Stage Provider Billing Manual Comment Log v0_4.xlsx HPE
1/26/2017 Updates based on Department 1/20/2017 approval email HPE
12/12/2017 Manual revised to separate NEMT and EMT services. Changed the name to NEMT Billing Manual. Updates made throughout to align with current policies and billing rules. HCPF
4/12/2018 Corrected Wheelchair Van procedure code HCPF
6/22/2018 Updated billing and timely to point to General Billing manual HCPF
6/28/2018 Edited link, edited timely HCPF
11/15/2018 Clarified interfacility transfers, 9-1-1 response calls, and unit limits for ancillary services. Removed crossover claim example. Added Urgent Transportation. HCPF
12/21/2018 Clarification to signature requirements HCPF
3/18/2019 Clarification to signature requirements HCPF
7/11/2019 Updated Appendices links and verbiage DXC
11/20/2019 Changed specific term to "transportation vendor" DXC
12/9/2019 Updated SDE entry to IntelliRide; added link for provider contacts HCPF
12/19/2019 Converted to web page HCPF
9/14/2020 Added Line to Box 32 under the CMS 1500 Paper Claim Reference Table HCPF
12/17/2020 Updated SDE entry to reflect IntelliRide as the statewide broker HCPF
12/29/2020 Added information on modifiers for billing multiple daily trips per member HCPF

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