Ground Emergency Transportation and Non-Emergency Transportation Billing and Documentation Requirements
| Date: | June 26, 2024 |
| From: | Health Plan |
| To: | Health Plan of San Joaquin/Mountain Valley Health Plan (“Health Plan) Practitioners and Hospitals Non-Emergency Medical Transportation (NEMT) & Ground Emergency Medical Transportation (GEMT) |
| Type: | Regulatory |
| Subject: |
Ground Emergency Transportation and Non-Emergency Transportation Billing and Documentation Requirements |
| Business: | Medi-Cal Managed Care |
Non-Emergency Medical Transportation (NEMT)
Non-Emergency Medical Transportation is covered when a member’s medical and physical condition does not allow that member to travel by bus, passenger car, taxicab, or another form of public or private conveyance.
Authorization
Authorization is required for NEMT, and the authorization number must be entered in the Prior Authorization Number field (Box 23) of the claim when billing for NEMT. An authorization, prescription or clinician signature is not required for NEMT from an acute care hospital to a long-term care facility. This is the only exception to the authorization requirement for NEMT, as stated in CCR Title 22, Section 51323[b](c).
The referring physician’s name should be entered in the Name of Referring Provider or Other Source field (Box 17) and NPI in Box 17B of the claim form, when a written prescription from patient’s physician is required.
Multiple Trips for Same Member
Multiple trips for the same member are provided on the same date of service. Enter the time of day and the points of destination in the Additional Claim Information field (Box 19) of the CMS-1500 claim. Without this information documented, second and subsequent trips may be denied as duplicate services.
HCPCS codes for NEMT
The appropriate HCPCS codes for NEMT are: A0130, A0380, A0422, A0425, A0426, A0428, T2001 and T2005.
Place of Service Codes for NEMT
41 A land vehicle specifically designed, equipped, and staffed lifesaving and for transporting the sick or injured.
Ground Milage
For litter van and wheelchair van transport, use HCPCS code A0380 (BLS mileage [per mile]) for non-emergency services only.
For ambulance transportation mileage, use HCPCS code A0425 (ground mileage, per statue mile) when billing mileage for both emergency and non-emergency services.
Mileage Documentation
When billing mileage, use either A0380 or A0425 as appropriate. Be sure to show the total miles from the point of member pick-up to destination (and return mileage for round-trip billing) in the Days or Units field (Box 24G). The complete origination and destination addresses, including city and ZIP code, must be indicated in the Additional Claim Information field (Box 19) of the CMS-1500 claim.
Night Call Claim Documentation
When billing for transport services between the hours of 7 p.m. and 7 a.m. providers will need to use the appropriate HCPCS code with modifier UJ (services provided at night). Indicate the start and stop time in the Additional Claim Information field (Box 19) of the CMS1500 claim form or on an attachment.
Ground Emergency Medical Transportation (GEMT)
All emergency medical transportation requires both:
- The emergency service indicator on the claim. Mark the EMG field (Box 24C) on the CMS-1500 claim form.
- A statement in the Additional Claim Information field (box 19) of the CMS-1500 claim form or an attachment, supporting that an emergency existed. The statement may be made by the provider of the transportation and must include:
- Nature of the emergency
- Name of the hospital or acute care facility to which the recipient was transported.
- Do not include an acronym in place of a hospital or acute care facility name. Abbreviations are acceptable.
- Name of the physician (Doctor of Medicine [M.D.] or Doctor of Osteopathic Medicine [D.O.], accepting responsibility for the recipient). The name of the staff M.D., D.O. emergency department or medical director is acceptable.
Additional information on billing please reference links: https://mcweb.apps.prd.cammis.medi-cal.ca.gov/assets/3E21E684-267F-418B-B5DC-4531DD2B73E1/mctrangndex.pdf?access_token=6UyVkRRfByXTZEWIh8j8QaYylPyP5ULO
GEMT Supplemental Payment
What Provider types are eligible for this supplemental payment?
- Non-contracted GEMT providers that provide services to Health Plan members are eligible for add-on payment.
Which service settings are excluded from this directed payment?
- Any transport billed when following evaluation of a patient, transport was not
- Service lines in a denied
- Emergency ambulance transports which originate outside the of the State of California
- Dual eligible beneficiaries with Medicare Part B coverage and without a Medicare crossover claim.
How often will payments be disbursed?
- Health Plan will pay GEMT add-on payments monthly. For each payment cycle, we will pay GEMT add-on payments for claims paid by the cutoff date for the corresponding service months.
- GEMT add-on payments are processed separately after the initial submission is paid. The GEMT add-on payment is not included with the initial claim payment.
- GEMT add-on payments will be made within 90 calendar days of initial claim receipt per Department of Healthcare Services (DHCS) guidance.
What is the Provider Dispute process related to GEMT add-on payments?
- If a Provider has a dispute regarding GEMT add-on payments for a claim that has passed the 90 calendar days of initial claim receipt, then the Provider may complete the Prop 56/GEMT Payment Dispute form found on Health Plan’s website at: https://www.hpsj.com/wp-content/uploads/2024/04/HPSJ-MVHP-Supp.GEMT_PDR-2024.pdf
How long does a Provider have to file a dispute regarding GEMT payments?
- A Provider has 365 calendar days from the add-on payment date to file a dispute regarding add-on payments.
- DHCS allows 90 calendar days from the date of receipt of a clean claim to issue GEMT add-on payment. Disputes submitted prior to this 90-day window will lead to denial or rejection of the dispute.
If you have any further questions, please contact your Provider Services Representative, or call our Customer Service Department at 1-888-936-PLAN (7526). You may also visit https://www.hpsj.com/alerts/ for online access to the documents shared. The most recent information about Health Plan and our services is always available on our website WWW.HPSJ-MVHP.ORG
