NEMT trip reconciliation: matching every completed trip to what you were paid

What trip reconciliation is, and why it runs weekly

Trip reconciliation is the check that ties your dispatch records to your bank account. Each trip leg, meaning a single ride between two addresses, should pass through four stages: scheduled, completed, billed, and paid. When a leg stalls or skips a stage, money is missing or money is wrong.

The routine pays for itself in three ways:

• Revenue you would otherwise lose. A completed ride nobody billed is worth nothing once the filing window closes. WellTrans refuses to pay any Indiana invoice submitted over 90 days after the service. New York wants the trip attested inside 30 days and claimed inside 90.
• Money you are not allowed to keep. Federal law defines an overpayment as Medicare or Medicaid funds a person holds “after applicable reconciliation” without being entitled to them. The statute allows 60 days from identification to report the overpayment, explain why it happened, and pay it back. Holding it past that deadline turns it into a False Claims Act obligation.
• Your standing with payers. Brokers score billing quality. MTM Health’s Virginia handbook expects denials on fewer than 0.29 percent of claims, and wrong or missing data on fewer than 0.99 percent.

Weekly fits inside the shortest payer clocks and lines up with broker pay cycles. Verida’s Indiana fee-for-service claims close each Wednesday, and MediTrans’s Louisiana payment run falls on every other Friday.

The four stages every leg passes through

Reconcile each stage against the next one. Each comparison catches a different kind of problem.

A leg that never carried a rider does not belong in the billed column. Louisiana’s managed care manual bars billing a scheduled trip with no enrollee on board. Colorado names cancellations among the things its NEMT benefit excludes, and federal Medicaid guidance treats empty miles, like the return leg a van drives with nobody aboard after a no-show, as something states generally may not pay for as a separate service.

A weekly reconciliation routine

Pick one morning a week and reconcile the week that ended a few days earlier, so late trip records have come in.

1. Lock the period. Pull every leg scheduled for the week, from every payer: brokers, facilities, and private riders.
2. Give every leg an outcome. Completed, rider no-show, canceled (and by whom), or reassigned. No leg should still read scheduled or in progress.
3. Check the documentation on completed legs. Signature, pickup time, drop-off time, miles, and anything else the payer requires. Fix gaps now. New York, for example, only accepts corrections to an authorization before you attest the trip.
4. Compare completed with billed. Every completed, billable leg should appear on a claim or invoice. Anything missing gets billed today.
5. Compare billed with completed. Every billed leg should have a completed record behind it. A billed cancellation or no-show gets voided or corrected.
6. Scan for duplicates. Same rider, same date, same pickup and destination, or overlapping times. Also check for one leg billed to two payers.
7. Compare paid with billed. Post each statement against the legs it covers, and mark each one paid in full, paid short, denied, or offset. A deposit you cannot tie to any leg goes on the exception list too.
8. Age what is still open. Sort unpaid legs by days since submission and compare each with that payer’s normal cycle. Anything past its cycle needs a status check.
9. Write the exception list. Each item gets an owner, an action, and the deadline that applies to it.

For Medicaid programs and health plans that take electronic claims, HIPAA’s standard status inquiry is the X12 276/277 pair, adopted at 45 CFR 162.1402, and payers that pay electronically send the X12 835 remittance advice, the HIPAA standard at 45 CFR 162.1602. Brokers show status in their own systems. MediTrans, for one, gives online and phone status for every claim it receives.

Finding rides nobody billed

Unbilled rides hide in the gaps between the road and the office. The usual sources:

• Trips closed in the field but not in the office. The driver finished the ride, but nobody moved it to billing.
• Will-call returns. The return leg of a will-call trip is often scheduled late in the day and billed separately from the outbound leg.
• Same-day additions. Discharges and add-ons booked by phone that never made it onto the broker’s roster or a facility invoice.
• Paper trip logs. Logs that sat in a van for a week.

Count unbilled legs every week and bill them the same day you find them. Then fix the cause, because the same gap will produce the same misses next week.

Catching duplicates and trips that never ran

Duplicates and phantom trips carry the most risk, because they turn into overpayments and penalties.

Exact duplicates. Payers flag them. X12 reason code 18, “Exact duplicate claim/service,” is meant to be used with group code OA. Sending a brand-new claim to fix one already on file can draw that code. To change a claim you already sent, use the payer’s correction process. On the 1500 form, item 22 takes a frequency code (7 replaces an earlier claim, 8 voids it) plus the reference number the payer gave the original claim. The guide to corrected NEMT claims covers the process.

Trips billed but not run. WellTrans assesses $50 per trip invoiced that you never ran, unless you can show the invoice came from a clerical mistake. A no-show that slipped onto an invoice is a trip not performed, so catch it before the broker does.

Impossible combinations. Brokers look for them in your data. MTM Health’s Virginia program counts overlapping claims, such as a single driver appearing in two vans at once or two drivers in one van at once, and expects fewer than 0.99 percent. Run the same check on your own records before a broker does.

When the check turns up money you should not have, return it. The 60-day clock in the federal overpayment statute starts when the overpayment is identified. For broker trips, the broker’s process governs. In Virginia, MTM Health asks providers to reach their field monitor, and MTM then voids the claim.

Explaining every short payment

A short pay is any payment below the amount you expected for a leg. Some are normal and some are errors. Sort them before you write anything off.

The remittance advice guide explains the codes on electronic statements, and the claim reason codes glossary entry lists the ones transportation providers see most.

Claims that disappear

Some billed legs never show up on any statement. Before assuming the payer is late, check whether the claim was ever accepted. A MediTrans rejection, for example, stays visible only in the portal with its reason. The remittance skips it because the claim never reached processing. Under the federal Medicaid definition in 42 CFR 447.45, a claim counts as clean only when the payer needs nothing further from you or a third party to process it, and the fastest payment standards cover clean claims alone.

Every week, list billed legs with no payment, no denial, and no rejection, and check each one in the payer’s portal or claim status tool. The accounts receivable guide covers the follow-up routine for older balances.

Example: one week, six legs

The figures below are made up. They show a small fleet’s week, trimmed to six legs, each with a different result.

Five of the six legs needed action, and each needed a different fix.

Tracking reconciliation over time

Keep a short scorecard so you can see whether the fixes are working:

• Unbilled legs at the end of each week. The target is zero.
• Days from ride to bill. Shorter is better, and it protects every filing window.
• Denials and rejections as a share of claims. Compare with payer targets, such as MTM Health’s 0.29 percent denial standard in Virginia.
• Short-pay dollars disputed and recovered.
• Overpayments found and returned, with the date found and the date returned.

The NEMT KPIs guide covers the operating measures that sit alongside these.

Where HealthRide helps with reconciliation

In HealthRide, every trip leg is stored as a separate record, with its status, signatures, GPS-recorded miles, and the times it was scheduled and actually ran. Completed trips become invoices, priced by the rate schedule attached to that payer, and each payment (card, check, or broker deposit) is recorded against the trips it covers. The past-due list and the payer report show what is still open for each payer.