NEMT billing in Massachusetts

Brokered through two regional transit authorities, with fee-for-service for the rest. The Montachusett Regional Transit Authority (MART) coordinates trips for Western, Central and Northeastern Massachusetts and the Metro Boston area, and the Greater Attleboro and Taunton Regional Transit Authority (GATRA) coordinates trips for Southeastern Massachusetts and Cape Cod. The member's MassHealth provider completes an online transportation request, the PT-1, approval may take up to three business days, and the broker then assigns each trip to a transportation company on a low-cost, most appropriate basis and on vehicle availability; Human Service Transportation policy does not allow members to choose their own vendor.¹ In the regulations a transportation broker is an entity that, under a selective contract with the Executive Office of Health and Human Services, procures and manages non-emergency transportation for members in a designated area, and MassHealth may make those contracts with brokers such as regional transit authorities. Transportation not furnished under a selective broker contract is non-brokered fee-for-service: the state plan says MassHealth pays its transportation providers directly for in-state non-brokered non-emergency transportation by ground ambulance or other means suitable to the member's condition, and any qualified and willing provider may participate. MassHealth pays brokers or fee-for-service providers only when public transportation is not available, and members are expected to use public or personal transportation, including family or friends, whenever possible.

Medicaid provider enrollment in Massachusetts runs through the Provider Online Service Center (POSC) web portal¹⁴. MassHealth brokers non-emergency rides through two regional transit authorities under selective contracts, MART for Western, Central and Northeastern Massachusetts and Metro Boston and GATRA for Southeastern Massachusetts and Cape Cod, and each broker assigns trips to the transportation companies in its own network¹.

MassHealth provider eligibility under 130 CMR 407.405 comes first for any company that bills MassHealth directly: submit an application to become an approved MassHealth provider; own, lease or otherwise control by written agreement the vehicles for the services sought; be a Medicare provider for any Medicare-covered service offered; and be assigned a MassHealth provider number. Staff whose positions could involve unsupervised contact with members provide written references and undergo a CORI check before any contact, new employees before hire and existing employees on annual recertification. The provider must not be excluded from any federal health care program and must screen against the OIG exclusion list monthly, each driver must hold a valid driver's license, and the provider must have a process for violations of state drug law and a process to disclose each driver's traffic violation history to MassHealth. Approval covers wheelchair van, ambulance or other licensed carriers, subject to selective contracting.⁴ Brokered work is a separate contract with the regional transit authority. GATRA asks a prospective vendor to request its Human Service Transportation Provider Application by email and to show at least one year of medical transportation experience, registration with the Secretary of the Commonwealth, a Certificate of Good Standing and an office in or near its territory. Where MassHealth places a region's services under a selective contract it may terminate existing provider agreements for those services on at least 30 days' written notice, without affecting payment for services already provided.

• A log or trip sheet, separate from the claim form, with the member's name, the date of service, the origin and destination of the trip and the vehicle identification number130 CMR 407.471 requires this for wheelchair van trips and the names of all passengers when more than one rides; 130 CMR 407.481 adds the vehicle number, the time of the trip, the driver's name and the nature of the ambulance service for ambulance runs.
• For a brokered trip, the approved PT-1 behind the broker's assignmentThe PT-1 is completed and submitted by an authorized provider or a managed-care, day habilitation or early intervention representative and approved by MassHealth, with recurring approvals limited to six months for acute illness, one year for chronic illness, three years for early intervention and five years for day habilitation; GATRA says approval may take up to three business days and the member is notified by mail.
• For a fee-for-service nonemergency trip, the Medical Necessity Form signed by an authorized provider or managed-care representative, kept by the transportation provider for six years from the date of serviceUp to 30 days of trips to the same destination may be authorized on one Medical Necessity Form.
• For an emergency ambulance run, the nature of the emergency recorded in detail, including the referring source
• Each driver's license, CORI result, monthly exclusion screening and traffic violation history on file for every driver named on a trip sheetThose are the 130 CMR 407.405 conditions of participation, and the state plan commits MassHealth to the same four minimum standards for every NEMT provider and driver.

Brokered trips are paid by MART or GATRA under the vendor contract rather than from a MassHealth fee schedule, and for wheelchair van the regulation points to Subchapter 6 of the Transportation Manual for the service codes, which this page does not reproduce. For fee-for-service ambulance, 130 CMR 407.481 sets the structure: a base fee, double the base fee when waiting time exceeds one hour, mileage per loaded mile only after 20 miles each way, half the base fee for a MassHealth member when more than one patient is carried with mileage charged once, and no separate payment for oxygen, a nurse or extra attendant, or waiting time.⁸ All claims to MassHealth are submitted electronically, by direct data entry on the POSC or as HIPAA transactions, claim status is available within 24 hours through the 276 and 277, and payment is reported on the 835 and the MassHealth remittance advice downloaded from the POSC. The NEMT billing codes page explains the transport codes and origin and destination modifiers in plain language.

90 days from the date of service, or from the date of another insurer's explanation of benefits, for a claim to reach the MassHealth agency under 130 CMR 450.309. A waiver can be requested when the person was not a member on the date of service but was later enrolled for a period that includes it, when the member failed to tell the provider about MassHealth eligibility in time, or in other cases MassHealth authorizes by transmittal letter or bulletin, and out-of-state services carry their own 90-day application window and a further 90 days after the approval notice.⁹ Brokered trips are paid by MART or GATRA under their vendor contracts, which set their own submission terms; the 90-day rule governs claims to MassHealth itself, and the MassHealth provider guide points late claims to the 90-day claim waiver request form.