What does a Medicaid provider agreement commit a transportation company to?
A Medicaid provider agreement is the contract between a state Medicaid agency and each enrolled provider. Under 42 CFR 431.107, it binds the provider to keep records showing the services it furnished, to hand those records and payment details to the state, CMS, or the fraud control unit on request, to make ownership disclosures, and to put its NPI on every claim.
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What federal rules put in every agreement
Every state plan must provide for a written agreement between the Medicaid agency and each provider, under 42 CFR 431.107. CMS’s Medicaid transportation coverage guide cites the same rule when it lists what states must require of the providers they pay. For a transportation company, the federal floor is four promises:
- Keep records needed to show the extent of the services you furnished to members.
- Hand them over on request, together with information on payments you claimed, to the state agency, the HHS Secretary, or the state Medicaid fraud control unit.
- Make the part 455 disclosures. Ownership and control details are due when you apply, when you sign the agreement, at revalidation, and within 35 days after a change of ownership. Business transaction details are due within 35 days of a request. Criminal convictions tied to Medicare, Medicaid, or Title XX must be disclosed before the agreement is signed or renewed. The ownership disclosure page covers who counts.
- Give the state your NPI and put it on every Medicaid claim.
A fifth item, on advance directives, applies to hospitals, nursing facilities, home health, hospices, and HMOs, not to transportation.
How a state writes it: Ohio
States add their own terms. Ohio’s rule, Ohio Administrative Code 5160-1-17.2, calls the agreement a contract between the Ohio Department of Medicaid and the provider. A provider signing it agrees to:
- Bill for services actually performed, at no more than its usual and customary charge to other patients.
- Look for other coverage first, then accept Medicaid’s allowed amount as payment in full, with no balance billed to the member or family.
- Keep records of services and significant business transactions for six years from payment, or until an audit started in that period ends.
- Supply records within 30 days of a request, or face withheld payments and possible termination.
- Report changes within 30 days, including licensure, ownership, and every address where it provides services.
Provider agreement vs broker contract
| Medicaid provider agreement | Broker contract (MTM’s standard agreement, as Pennsylvania posts it) | |
|---|---|---|
| Signed with | The state Medicaid agency | The broker |
| Terms come from | 42 CFR 431.107, part 455, and state code | The broker’s terms and its client contracts |
| Length | Revalidated at least every five years | Three years, renewed only by mutual written agreement |
| Record retention | Set by the state (Ohio: six years from payment) | Ten years, or longer where law or the client requires |
| Ending it | Ohio: provider gives 30 days’ written notice | Either side on 30 days’ notice, and the broker can end it at once for listed causes |
The MTM agreement also states that it guarantees no minimum number of trips.
How agreements end
Federal rules list reasons a state must end enrollment, in 42 CFR 455.416. They include ownership information that is missing or inaccurate, a 5 percent owner with a program-related conviction in the last 10 years, termination by Medicare or another state, fingerprints not supplied within 30 days, and refusing a site visit. For several of these, the state may keep the provider if it documents in writing that ending enrollment is not in the program’s best interest. Enrolled providers must also allow unannounced inspections of any location.
State rules add more. Ohio can move to end an agreement when a provider has not billed Medicaid in two years or more. The guide to Medicaid provider termination covers appeals and how a termination follows a company.
Keeping the records the agreement asks for
When the state or a broker asks for proof of a ride, HealthRide’s trip log already holds it: each leg’s planned and actual times, both addresses, the driver and van, and GPS-recorded miles. Download it as a spreadsheet or a PDF ready to print. See reports.
Frequently asked questions
- Is my provider agreement the same as my broker contract?
- No. You sign the provider agreement with the state Medicaid agency, and its core terms come from federal rules and state code. A broker contract is with the broker and follows the broker's own terms and its contract with the state or health plan. Many transportation companies hold both, and each one can end on its own.
- How long do I have to keep trip records?
- Federal rules require records that fully show the services you provided but leave the retention period to each state. Ohio, for example, requires six years from the date you were paid, or longer while an audit that started in that window is open. Broker contracts can ask for more: MTM's standard agreement says ten years. Keep records for the longest period that applies to you.
- What happens if I do not send records when the state asks?
- Expect payments to stop. Ohio's rule says that failing to supply requested records within thirty days leads to withheld Medicaid payments and may end in termination. Federally, a provider has 35 days to answer a request for business transaction details, and federal matching money is denied for services during any delay after that.
- Can I end my provider agreement myself?
- Yes, under the terms your state sets. In Ohio, a provider may end its agreement with written notice 30 days before the chosen date, although the state can refuse a voluntary exit while it is taking action against the provider. Letting revalidation lapse also ends it: Ohio terminates agreements that are not revalidated on time.
