Billing Medi-Cal NEMT trips: the codes and what a clean claim needs

Medi-Cal transportation reaches a provider through two doors. Fee-for-service (FFS) trips are billed to Medi-Cal itself. Managed care plans cover NEMT for their own members, and a plan may contract a transportation broker to schedule rides and pay providers. Most providers in California work with several plans and brokers at once.

Each door has its own rules for claims. Brokers usually take claims through their own portal or file format. FFS Medi-Cal and many plans take the CMS-1500 claim, on paper or as its electronic form, the 837P. The codes below come from Medi-Cal's ground transportation manual, and plans that bill on the CMS-1500 use them too. A broker or plan can still ask for its own codes, modifiers or fields, so the contract and the payer's current manual always win.

Medi-Cal covers NEMT when a member's medical and physical condition rules out ordinary public or private transport, and a provider prescribes it in writing. That written order is the Physician Certification Statement (PCS) form. It can be signed by a physician, dentist, podiatrist, mental health or substance use disorder provider, or a physician extender such as a physician assistant or nurse practitioner.

Under DHCS All Plan Letter 22-008, managed care plans must keep a complete PCS form on file for every member who gets NEMT. A PCS for recurring appointments, such as dialysis, can cover up to 12 months. The form names the mode of transport, and neither the plan nor its broker may change or downgrade it. If the member's condition changes, a new PCS is needed.

A few transfers need no PCS, such as a move from an emergency room to an inpatient setting, or from an acute care hospital straight to a skilled nursing facility after an inpatient stay. For everything else, the authorization number belongs on the trip before the van leaves, not after the claim comes back denied.

Medi-Cal bills a van trip as a base code for the leg plus a mileage code for the loaded miles. These are the ones a wheelchair or stretcher van provider uses most:

• A0130: wheelchair van, the base code for the trip.
• T2005: stretcher van (Medi-Cal's manual calls it a litter van).
• A0380: mileage per statute mile for wheelchair van and litter van trips, non-emergency only. Medi-Cal moved van mileage to this code on July 1, 2016.
• A0425: ground mileage for ambulance trips only. It is not the mileage code for vans.

Health Plan of San Joaquin's 2024 billing alert lists the codes it accepts for non-emergency transport as A0130, A0380, A0422, A0425, A0426, A0428, T2001 and T2005. The ambulance codes belong to ambulance providers; the point for a van company is to keep A0380 on van legs and A0425 off them.

Medi-Cal also defines modifiers for some situations, such as night transport and certain dry runs, and the manual sets the order they go in. Health Plan of San Joaquin, for example, asks for modifier UJ on transport between 7 p.m. and 7 a.m., with the start and stop times on the claim. Check the codes and modifiers table in the current Medi-Cal manual, and your plan's own alerts, before you set up rates.

A clean claim is one the payer can pay without asking you anything. For CMS-1500 claims, Health Plan of San Joaquin spells out what it expects on a transportation claim, and it is a fair picture of what payers check:

• The authorization number (box 23).
• When a written prescription is required, the referring provider's name and NPI (boxes 17 and 17B).
• The complete origin and destination addresses, including city and ZIP code (box 19).
• Total loaded miles, plus the return miles on a round trip, as the units for the mileage line (box 24G).
• For a second or later trip for the same member on the same date, the time of day and destinations (box 19). Without them, later trips may be denied as duplicates.
• Place of service 41 for the land vehicle.

Behind the claim, keep the trip record that proves it: the driver and vehicle, the member's name and Medi-Cal ID, actual pickup and drop-off times, the addresses, the loaded miles, the authorization, signatures where the payer asks for them, and the GPS trail. If a payer audits the trip, this is what they will ask to see. Our post on trip sheets goes through that record field by field.

The same handful of reasons come back again and again. When they arrive on an 835 remittance, each comes with a standard claim adjustment reason code:

• No authorization on file (reason code 197: precertification or authorization absent).
• A second trip the same day that looks like a duplicate (code 18: exact duplicate claim or service).
• A modifier that does not fit the code (code 4).
• Missing information or a billing error (code 16), often an address, a ZIP code or the miles.
• Filed too late (code 29: the time limit for filing has expired).

Each of these can be caught before the claim goes out. A leg with no authorization, no signature or no miles should not be billable yet. Our guide to reading and posting an 835 shows how to post these denials so none is lost.

California law expects an original Medi-Cal fee-for-service claim within six months after the month of service. Welfare and Institutions Code section 14115 allows later claims, up to 12 months, at reduced payment, with exceptions for good cause. Plans and brokers set their own deadlines in their contracts, and these are often shorter. Put each payer's deadline in your billing calendar, and bill weekly rather than monthly so a held trip still has time to be fixed.

MileCall prices every performed leg from the payer's own rate card: per leg, per loaded mile, per minute of wait and per attendant, by space type and time of day. Miles are counted the way each payer pays: routed, GPS trail, odometer or imported, with that payer's rounding and caps. A leg missing a signature, an odometer reading, a GPS fix, an authorization or a rate is held back, with the reason in words. Authorizations are kept per rider and payer, with units, date ranges and an alert before they expire.

Claims go out today as trip sheets in each payer's own columns or as invoices; when the 835 comes back, it posts onto each leg. See MileCall billing for the details.

1. Medi-Cal Provider Manual, Part 2: Medical Transportation – Ground (DHCS, Medi-Cal)
2. Medi-Cal Provider Manual, Part 2: Medical Transportation – Ground: Billing Codes and Reimbursement Rates (DHCS, Medi-Cal)
3. Medi-Cal Provider Manual, Part 2: Medical Transportation – Ground: Billing Examples (DHCS, Medi-Cal)
4. All Plan Letter 22-008: Non-Emergency Medical and Non-Medical Transportation Services and Related Travel Expenses (DHCS)
5. Provider Update 22-972: Action required for NEMT requests (APL 22-008 summary and PCS form) (CalViva Health and Health Net, Medi-Cal plans)
6. Ground emergency transportation and non-emergency transportation billing and documentation requirements (June 2024) (Health Plan of San Joaquin, a Medi-Cal plan)
7. Welfare and Institutions Code section 14115 (Medi-Cal claim submission time limits) (California Legislative Information)
8. Claim Adjustment Reason Codes (X12)

This post explains how things work in general; it is not legal, medical or billing advice. Rules change and differ by payer, so check your payer’s current manual and your contract before you rely on any detail here.