Covered and Noncovered Services : Covered Services and Requirements

Non-Emergency Transportation

Nursing home non-emergency transportation is defined as transportation provided by a nursing home to permit a resident to obtain health treatment or care if the treatment or care is prescribed by a physician as medically necessary and is performed at a physician's office, clinic, or other recognized medical treatment center. Such transportation may be provided in the nursing home's own controlled equipment and by its staff, or by common carrier such as bus or taxi. The member must have an open nursing home LOC for the non-emergency transportation DOS.

Non-Emergency Transportation (NEMT) Trip

When a provider picks up the resident from their point of origin, takes them to their destination, and leaves, this is considered a single trip. The trip may involve one or more stops before reaching the destination, where the provider does not leave but waits for the resident to complete their business at the stop(s). In this case, the destination may be the same as the point of origin.

Claim Form

Providers are required to submit claims for nursing home non-emergency transportation on the 1500 Health Insurance Claim Form or by 837P transaction.

Procedure Codes for Non-Emergency Transportation

Providers are required to include one or both of the following procedure codes on claims for nursing home non-emergency transportation:

• A0120 (Non-emergency transportation: mini bus, mountain area transports, or other transportation systems)
• S0215 (Non-emergency transportation; mileage per mile)

When nursing home providers transport more than one member, a claim may be submitted for the base rate and mileage for each resident transported.

Multiple Trips on a Same Day

When a provider transports a member on more than one trip on the same day, the provider should use trip modifiers on the claim. Note: Trip modifiers U1, U2, U3, U4, U5, and U6 are used to identify procedure codes related to the same trip for the same member by the same provider on the same DOS.

Procedure Code for Transportation by Contracted Common Carrier Service

Nursing home providers who contract with a common carrier (for example, bus, taxi) service and are only billed a flat rate by the common carrier should only indicate the procedure code for the base rate, procedure code A0120, on the claim.

Nursing home providers who contract with a common carrier service and are billed a base rate plus mileage are required to indicate both procedure code A0120 and S0215. Indicate the base rate fee on the detail with procedure code A0120 and the mileage on the detail with S0215.

Exceptions for HMOs and Dual Eligible Members

Nursing home NEMT claims for members currently enrolled in an HMO or who are dually eligible for Medicare and Wisconsin Medicaid should be submitted directly to ForwardHealth by the nursing home provider, unless the member is admitted to the nursing home from the hospital, discharged from the nursing home to return home, or enrolled in hospice.

If a member is currently enrolled in a BadgerCare Plus HMO, the member does not require an LOC for the first 30 days of the nursing home stay. If a member is currently enrolled in a Medicaid SSI HMO, the member does not require an LOC for the first 90 days of the nursing home stay.

If the member is dual eligible with Medicare and Wisconsin Medicaid, providers must submit an LOC request when the Medicare benefits exhaust or the service is not covered under Medicare and would be covered under ForwardHealth.

Since these members do not have an open LOC on file, nursing home providers are required to submit claims with the UA modifier (NEMT billed for a member residing in a nursing home) for members enrolled in an HMO to avoid claim denials. SMV providers are required to submit NEMT claims with the UA modifier for either members enrolled in an HMO or members who are dually eligible to avoid claim denials.