Billing a NEMT trip that was not completed: breakdowns, hospital admissions, and cancelled appointments

The rule under every case

A payer pays for a leg that ran start to finish while carrying the rider, and for nothing it cannot see happen. Federal rules define Medicaid transportation as the expense the state judges necessary to get a beneficiary to medical examinations and treatment (42 CFR 440.170(a)). State manuals and broker handbooks turn that into blunt rules:

• New York pays nothing when transportation was not actually provided. Before a trip can receive a prior authorization number and be billed, the provider must attest that it was completed, and the record for each leg carries the driver’s statement that the ride happened, or a no-show note if it did not.
• MTM Health in Virginia turns down a claim unless the trip shows as complete when it is submitted. The claim also fails when the trip log is missing the trip ID, the scheduled or actual pickup time, the departure or arrival time, or the member’s signature.
• Colorado excludes charges incurred while the member is not in the vehicle (lodging and meals aside), cancellations, and response calls where nobody was transported.
• Texas considers only claims for services rendered. Under its Medical Transportation Program handbook, a missed appointment is billable to nobody, Medicaid or client.
• CMS allows no federal match for a provider no-show, because no covered service took place (SMD 23-006, September 28, 2023).

Mileage follows the same logic. New York reimburses only loaded miles, the miles during which the rider occupies the vehicle. When a leg is cut short, the miles that count are the ones covered while the rider sat in the van.

When the rider is kept in the hospital

A return leg that never runs is cancelled, not billed. Let the broker know the moment the clinic or family says the rider is staying, so the leg comes off your schedule and the broker’s records match yours. The trip cancellations guide covers the reporting side.

What happens during the stay differs by payer:

• New York. Once a Medicaid member is admitted to a hospital licensed under Article 28 of the Public Health Law, the hospital’s payment covers the transportation the inpatient needs. When the admitting hospital sends the inpatient to another hospital for a test and back, the admitting hospital pays the transportation company. The details are in who pays when an inpatient goes to another hospital.
• Medi-Cal. A rider who stays an inpatient can be carried and billed under place of service 21, with boxes 32 and 32A naming the inpatient hospital and giving its NPI. A hospital to doctor’s office trip and the ride back, billed as two trips, both take place of service 21.
• Standing orders. MO HealthNet’s broker deactivates a member’s standing order when told of a hospitalization. After discharge, the broker has to arrange a fresh standing order before rides resume. Recurring legs scheduled during the stay are not yours to run or bill.
• The escort. Colorado pays for the escort’s one-way trip back (T2001) in one case: the member is moving into a facility or a residential treatment program, and the escort goes home alone.

The ride home after discharge is a new trip with its own authorization. Some programs skip prior authorization for it. Medi-Cal waives it for a patient going straight from an acute inpatient stay into a licensed nursing facility, skilled or intermediate care. California’s All Plan Letter 22-008 gives plan members the same exception and adds emergency room to inpatient transfers. See hospital discharge transportation.

The van breaks down partway

A breakdown mid-leg splits the trip between the van that started it and the vehicle that finishes it. The roadside steps are in the vehicle breakdown plan. The billing turns on three points.

Report it while it is happening. Medical Answering Services, New York’s statewide broker, expects to hear right away when weather, an accident or another emergency keeps a provider from starting or finishing a trip. Modivcare’s Mississippi manual normally lets it charge a provider for the extra cost of replacement transportation when a trip is rerouted without 24 hours’ notice. A sudden breakdown or accident is exempt, provided it is reported when it happens, and paperwork is required before that vehicle carries riders again.

The broker reassigns the rest. New York does not let one transportation company pass a trip to another or lease another company’s vehicle. When a company runs short of vans, it must tell the broker, and the broker places the ride with another provider. New York’s Office of the Medicaid Inspector General disallows any claim for a trip a subcontractor ran. In Colorado, when different rendering providers ran one member’s trips that day, the claims carry modifier 77.

The unfinished leg rarely pays. MTM’s Virginia handbook rejects trips not marked complete, and New York ties every claim to the provider’s statement that the ride took place. Ask the broker how the cut-short leg will be recorded, and bill nothing for it without that answer in writing. The company that finishes the ride bills its own leg and its own loaded miles, from where it picked the rider up.

The appointment is cancelled after pickup

A rider can arrive at a dark office: wrong date, a holiday, a visit cancelled without anyone telling the ride. Payment for that trip is far from certain:

• Wisconsin. A specialized medical vehicle trip, the return included, is paid on one condition: the rider receives a service Medicaid covers at the destination on that date (Wis. Admin. Code DHS 107.23(1)(c)4).
• New York. Auditors disallow transportation that did not go to or from the location of a Medicaid-covered service, under the protocol criterion titled “The Medical Service Could Not Be Corroborated for the Transportation Service Provided.”
• New York broker rules. At the ambulette level and higher, riders are not dropped off before the office opens. A door-through-door rider is never left at a building that is shut or cannot be entered, and rides back to the original pickup point instead.

The practical rule is to call the broker before turning around. Record who at the clinic said the visit was off, the time, what the broker decided, and any new authorization for the ride back. What dispatch does with the rider in the moment is covered in clinic closed when the rider arrives, and the timing rules sit under appointment time.

The rider changes the plan mid-ride

Riders ask to stop at a pharmacy, go somewhere else, or get out a few blocks early. Each request changes what the broker authorized, so treat it as a request to the broker, not to the driver:

• New York pays for a changed trip only when the change, such as a new destination or a different day, was approved before the ride. Medical Answering Services adds that changes asked for after a ride may not be approved.
• Modivcare has to sign off in advance on any new pickup time, so it can track on-time performance.
• Missouri caps a member’s day at three legs, or two stops, unless the MO HealthNet Division approves more.

If a rider gets out before the destination, call the broker at once and note the time and place. Bill the leg only as the broker records it.

Trips that end before the rider boards

A van that arrives and leaves empty has run a dry run, and Medicaid programs generally pay nothing for it. The rider side of the rule is covered under no-show billing. Colorado lists response calls with no transport among its exclusions.

Medi-Cal fee-for-service is the notable exception. It pays for responding to a call without transporting the recipient:

• The codes. The transport’s base code takes modifier DS followed by QN. Stretcher van (T2005) and wheelchair van (A0130) codes sit on the dry run list next to the ambulance codes.
• Hospital to nursing facility. When the call was for an acute hospital discharge into a Level A or B nursing facility and nobody rode, HN goes before QN on A0130, A0426, A0428 or T2005. No TAR is required.
• Night calls. For an empty response at night, UJ goes on the line and Box 19 gives the time.
• Mileage. Medi-Cal will not pay mileage on the same date as a dry run for one recipient and provider, unless the record ties the miles to a ride actually given at another hour.

What to write down when a trip changes

The notes made at the time decide whether a changed trip gets paid. New York holds providers to records created when the service happens, covering each leg, and they must survive six years past payment. Have the driver and dispatcher capture:

1. Where and when the leg ended. Medi-Cal lets vehicle GPS or mapping software replace the odometer at every stop.
2. Why it ended. Admitted, breakdown, office closed, or the rider’s request, in plain words.
3. Who was told. The broker contact, the time, and the reference or decision they gave.
4. The new authorization. The number for any leg added or changed.
5. Who finished the trip. The company, vehicle and driver that ran the rest.
6. Signatures only for finished legs. The rider’s signature or the driver’s completion statement belongs on a leg that actually reached its destination.

A record fixed later should read as a correction, dated and with the original still visible. Correcting NEMT trip records covers how auditors expect that to look.

When one leg changes

HealthRide tracks status leg by leg, so a cancelled ride home sits next to a completed ride out without either one changing the other. Each leg keeps its own signatures and GPS-recorded miles, along with recorded wait times on no-shows, and the trip log puts planned and actual times side by side. On the dispatch board, any leg still waiting to run can be dragged onto a different driver.