Covered and Noncovered Services : Covered Services and Requirements

General Non-Emergency Medical Transportation Information

Members are eligible for NEMT if they have no other way to receive a ride to a covered appointment. If members are financially able to drive themselves to the covered appointment or if neighbors, friends, relatives, or voluntary organizations are able to provide transportation at no cost, the member is not eligible for transportation through the NEMT manager contracted with the Wisconsin DHS. Providers should note that a "ride" can also mean public transportation.

For members eligible to receive a ride through the NEMT manager to their covered appointments, the NEMT manager is required to schedule the least costly type of ride that meets the member's medical and transportation needs per 42 C.F.R. § 447.200. The NEMT manager will require members to ride a bus to their covered appointment when appropriate. The NEMT manager may be able to offer mileage reimbursement to members who have a car and are able to drive themselves to their covered appointment but are unable to pay for gas.

For members unable to ride a bus and unable to use their own car, the NEMT manager will coordinate a ride with the most appropriate type of vehicle based on the member's medical and transportation needs. Rides may include an SMV or other type of vehicle. Members may be required to share a ride with another rider during their trip to their covered appointment.

Three modes of NEMT are covered for members who do not have any other means of transportation going to and from services that are covered by the program in which they are enrolled. Modes of NEMT include:

• Common carrier transportation
• SMV transportation
• Non-emergency ambulance transportation

Common Carrier Transportation

Common carrier transportation is transportation by any mode other than ambulance or SMV. Common carrier vehicles or providers are not required to be enrolled in Wisconsin Medicaid but must be under contract with the NEMT manager. These vehicles are not required to have permanently installed ramps or lifts and are not enrolled for cot or stretcher transportation. This may include vehicles such as public transportation, volunteer vehicles, and HSVs. HSVs must maintain a current State Patrol HSV inspection.

Specialized Medical Vehicle Transportation

SMVs are vehicles that are equipped with permanently installed ramps or lifts and are required to be enrolled in Wisconsin Medicaid. SMVs that are also used for cot or stretcher transportation must meet the additional requirements of Wis. Admin. Code § DHS 107.23(3)(b).

To be eligible for SMV transportation, a member must have a documented physical or mental disability that prevents them from traveling safely in a common carrier or private motor vehicle to a covered service. To be eligible for transport on a cot or stretcher, a member must require transport in a supine position.

The NEMT manager provides coordination and reimbursement for Medicaid-enrolled SMV providers for NEMT. SMV providers must be contracted with the NEMT manager and submit claims directly to the NEMT manager in order to receive reimbursement. The referring hospital, clinic, or other originating facility coordinates the transportation through the NEMT manager.

Certification of Need

Members receiving NEMT through the NEMT manager are not required to have a Certification of Need for Specialized Medical Vehicle Transportation form signed by a physician, nurse practitioner, or physician assistant on file prior to receiving SMV services. However, the NEMT manager may verify in other ways whether or not an SMV is the appropriate mode of travel for a member.

The Certification of Need for Specialized Medical Vehicle Transportation form is required for SMV services provided to ForwardHealth members not affected by the NEMT management system.

Non-Emergency Ambulance Transportation

To be eligible for non-emergency ambulance transportation, a member must require life support services (either ALS or BLS), require transportation in a supine position, or suffer from an illness or injury that prevents them from traveling safely by any other means.

The NEMT manager provides coordination and reimbursement for Medicaid-enrolled ambulance providers for NEMT. Ambulance providers who provide NEMT to covered members must be contracted with the NEMT manager and must submit claims directly to the NEMT manager in order to receive reimbursement for these transportation services.

The NEMT manager also reimburses claims for limited medical services provided during a non-emergency ambulance trip. Providers should continue to submit claims to ForwardHealth for most medical services provided during a non-emergency ambulance trip. Refer to a complete list of ALS and BLS procedure codes that should be submitted to ForwardHealth in all circumstances (whether transporting under emergency or non-emergency cases).