NEMT billing in Florida

Two tracks: recipients in a Statewide Medicaid Managed Care plan get transportation through the plan and the vendor it contracts, while fee-for-service recipients are served under the 1915(b) Non-Emergency Medical Transportation waiver by two capitated vendors that the Agency for Health Care Administration pays per member per month and assigns by region, Modivcare in regions A, G, H and I and Medical Transportation Management, Inc. (MTM) in regions B through F.¹ The waiver renewal runs July 1, 2025 to June 30, 2027. The vendors handle centralized call intake, eligibility determination, trip authorization, scheduling, dispatching and monitoring of transportation providers, and may provide services directly or subcontract for them. A recipient is assigned to the vendor for the region where they live, and a recipient who enrolls in an MMA plan is disenrolled from the waiver.

Medicaid provider enrollment in Florida runs through the Florida Medicaid Web Portal⁴. Fee-for-service riders are served under the 1915(b) NEMT waiver by Modivcare in regions A, G, H and I and by MTM in regions B through F; Statewide Medicaid Managed Care plan members ride through their plan's transportation vendor¹.

For fee-for-service trips you join a waiver vendor's network. Each vendor maintains its own transportation provider list for its regions, must keep contracts with enough providers that trips are prompt and reasonably accessible, and must file a Provider Termination and New Provider Notification Report with the Agency by the fifteenth day of the following month. The Agency assessed the vendors on their network requirements including vehicles, compliance with vehicle and equipment safety standards and the Americans with Disabilities Act, encounter data submission and timely payment of claims.¹ For plan members, the plan's vendor sets its own network terms; Sunshine Health points providers to the Alivi or MTM website to request an account. Florida Medicaid enrollment itself, Full or Limited, is filed through the Online Enrollment Wizard on the Florida Medicaid Web Portal, cited below, and a billing agent submitting on your behalf must be enrolled before it receives a trading partner ID.

• Recipient name and Medicaid identifier, pickup and drop-off locations, the date and time of service, and the loaded milesThe CMS booklet lists these as the minimum every state requires a transportation provider to document, with only loaded miles recorded.
• The scheduled appointment time and the actual pickup and arrival time for each legThe waiver, cited below, holds the vendors to recipients arriving within 15 minutes of the Leg A appointment time, Leg B pickups within 30 minutes of the scheduled time, and unscheduled trips within three hours, and the vendors compile those timeliness reports from claims data, so your times are the evidence.
• Verification that the trip was to and from a medical purposeBoth waiver vendors complete pre- and post-verification of trips for medical purpose and audit for fraud and abuse.
• Recipient signature on the transport record where the vendor or plan requires itThe CMS booklet says some states and brokers require the beneficiary's signature at the end of the trip and that management should verify the record by calling riders and appointment sites.
• Vehicle and driver credentials current on the date of serviceThe waiver vendors' quality teams check vehicle compliance through on-site inspections, and Section 209 of the Consolidated Appropriations Act, 2021, as Medicaid.gov describes it, requires valid driver licenses, exclusion list checks, a process for state drug law violations and disclosure of driving history.

Waiver trips are paid by the regional vendor under its subcontract with you, and plan trips by the plan's vendor, so the rate sheet in each agreement, not a state fee schedule, sets what a leg pays by mode. Each leg is billed the way that agreement specifies.¹ The waiver vendors submit encounter data to the Agency and are desk-reviewed on it monthly, which is why every field the vendor's trip record asks for has to be filled before the trip is submitted. For what each transport code and each origin and destination modifier means, in plain language, see the NEMT billing codes page.

Claims to the state Medicaid agency must be filed no later than 12 months from the date of service, the outside limit 42 CFR 447.45 sets for every state; the vendor and plan agreements set the windows for the trips they pay.⁵ Plans are shorter and differ from each other; Community Care Plan's MMA manual, cited below, denies claims received more than 180 days after the date of service. The waiver assessed the vendors on their ability to process timely payment of claims but publishes no payment window.