NEMT
DHCS makes NEMT subject to prior authorization: the member must have an approved PCS form. For recurring appointments, such as dialysis, the plan authorizes NEMT for the length of the treatment, up to 12 months.
No prior authorization is needed when a member is moved from an emergency room to an inpatient setting, or from an acute care hospital, right after an inpatient stay, to a skilled nursing facility, an intermediate care facility or an inpatient psychiatric facility.
NMT
Plans may require prior authorization for NMT and renew it every 12 months. An attendant’s ride is authorized together with the first NMT request.
What it means for the provider
The authorization number is usually what ties a leg to its payment: brokers and plans check that a leg had one, that the date was inside its range and that the units weren’t used up. A leg billed without it is a common denial. In fee-for-service Medi-Cal the authorization is a TAR.
Related terms
- Physician Certification Statement (PCS form)A Physician Certification Statement (PCS) is the form a member’s provider signs to prescribe NEMT.
- Treatment Authorization Request (TAR)A Treatment Authorization Request (TAR) is fee-for-service Medi-Cal’s approval for a service before it is paid.
- Standing orderA standing order, also called a subscription or recurring trip, is a trip that repeats on a pattern, such as dialysis every Monday, Wednesday and Friday.
- Trip sheet and manifestA trip sheet is the record of what happened on each leg that a payer asks for before it pays: times, miles, driver, vehicle and signatures.
Sources
Checked on . Rules change: check the current version with the payer before you bill.