What is prior authorization for NEMT trips?
Prior authorization is the payer's approval of a specific NEMT trip before it happens. The state, broker, or health plan confirms the rider is eligible, the destination is a covered service, and the mode fits the rider's needs. Without it, the claim is usually denied. Some programs require it for every trip, and others only for long-distance or special trips.
On this page
Who grants prior authorization
The program that manages the ride approves it. The approver changes with the delivery model:
- Broker programs. In Georgia, every NEMT ride must be scheduled and authorized by the broker. The broker’s booking is the approval.
- State programs. Texas’s Medical Transportation Program issues all prior authorizations for fee-for-service trips, and claims without one are denied.
- Health plans. Health Net in California needs a signed Physician Certification Statement before it grants prior authorization for an NEMT ride.
- Mixed models. New York calls the approver the prior authorization official. That is the Department of Health, its broker, or another entity the state permits.
CMS also lets states add special authorization steps for individual riders when past behavior made rides unsafe. Before limiting a rider’s transportation, the state should send a letter explaining why.
When it is required
| Program | What needs approval | Details |
|---|---|---|
| New York Medicaid | Every non-emergency trip | In most cases approval is needed before each trip or round trip. Repeat trips to the same place with the same provider can get a standing order approval. |
| Texas MTP (fee-for-service) | Every trip | Riders call at least two business days ahead, or five for trips outside their county. |
| Arizona AHCCCS (fee-for-service) | Trips over 100 miles in a day | The request must show the trip is to a covered service. Shorter ground trips need no approval. |
| California Medi-Cal (fee-for-service) | All non-emergency medical transportation | A prescription is also required. Urgent requests can go by phone but must be confirmed in writing. A transfer from an acute hospital stay to a skilled nursing or intermediate care facility is exempt. |
What a request includes
Texas lists what a rider gives the intake operator when requesting a ride:
- Name, address, phone if available, Medicaid ID or Social Security number, and date of birth.
- The medical provider’s name, address, and phone.
- The purpose, date, and appointment time.
- Confirmation that no other transportation is available.
- Special needs, such as a wheelchair lift or an attendant.
- A health care provider’s statement of need, when the program requires one.
An example
A New York dialysis patient rides three times a week to the same clinic with the same provider. Instead of one approval per trip, the broker can grant a standing order approval for an extended period. If the clinic moves her chair time to a different day, that change has to be approved before the first ride on the new day.
Prior authorization vs nearby terms
- Eligibility: whether the rider has Medicaid on the date of service. It is a separate check. New York denies an authorization request when the rider is not eligible on that date.
- Trip authorization number: the ID the approver issues once a trip is approved. It goes on the claim.
- Physician Certification Statement: documents the medical need for a vehicle type. In California it must exist before authorization is granted.
- Standing order: one approval that covers a series of repeat trips.
A missing or mismatched authorization can sink an otherwise clean claim. See NEMT claim denials and NEMT documentation requirements for the records to keep.
Standing orders pair well with recurring trips in HealthRide: schedule the series once and it keeps going.
Frequently asked questions
- Does prior authorization guarantee payment?
- No. New York's transportation manual says it plainly. A trip can be authorized and still go unpaid if the rider or provider does not meet eligibility rules on the date of service, or if the claim does not match the authorization.
- Can the transportation company request prior authorization itself?
- It depends on the program. In New York it is inappropriate for a transportation provider to request it, and the rider or ordering practitioner asks instead. In Texas the rider calls the Medical Transportation Program. In Arizona fee-for-service, the provider submits the request for trips over 100 miles.
- What if the trip changes after it is approved?
- Get the change approved before you drive it. New York requires any change to trip details, such as the location or the day, to be approved by the prior authorization official first, or the trip may not be paid. Send the rider to the broker to request the change.
