NEMT billing in Oregon

Brokerages, split by coordinated care organization and open card membership. Under OAR 410-136-3000 the Oregon Health Authority provides NEMT for eligible clients whether they are fee-for-service, in a prepaid health plan or in a CCO, but once a CCO offers NEMT the Authority serves only clients not enrolled in that CCO and may not pay for services the CCO covers, and transportation providers coordinate every ride with the client's brokerage or CCO.³ OHP calls the brokerages ride services, pays for travel only when the ride service approves it before the appointment, and limits NEMT to members with OHP Plus benefits; clients in the Citizen Alien Waived Emergency Medical and QMB-only benefit packages are not eligible under OAR 410-136-3020. Brokerages enrolled with the Authority arrange and pay for NEMT for all eligible clients in the counties listed in Table 136-3340, and the Authority's ride service map, effective July 1, 2023, sets out twelve service areas, most of them with one ride service for a CCO's members and another for everyone else.

Medicaid provider enrollment in Oregon runs through the MMIS Provider Portal¹². NEMT in Oregon is arranged and paid by the brokerage for the member's county and coordinated care organization, which the Authority enrolls as a provider, and a transportation company works as that brokerage's subcontractor¹⁰.

Two lanes: the brokerage's subcontract, and Authority enrollment only where you bill the Authority directly. OAR 410-136-3340 has brokerages enrolled with the Authority arrange and pay for NEMT in their counties, so a transportation company becomes a subcontractor to each brokerage whose members it carries. OAR 410-136-3040 sets the standards the brokerage checks: each driver holds a valid license of the class, with any endorsements, that the vehicle needs under ORS Chapter 807, passes a criminal background check under ORS 181.534 and 181.537, and completes a defensive driving course, Red Cross-approved first aid, CPR and blood spill procedures courses, and a Passenger Service and Safety course within six months of hire, repeating defensive driving and passenger safety at least every three years and keeping the first aid and CPR certifications current. Vehicles carry safety belts, a first aid kit, a fire extinguisher, reflective devices, a flashlight and tire traction devices as appropriate, keep a clean interior and working mirrors, horn, signals, lights and wipers, and follow the manufacturer's preventive maintenance schedule.⁵ Under OAR 410-136-3060 brokerages carry general and automobile liability coverage for personal injury, death and property damage naming the State of Oregon and the Oregon Health Authority as additional insureds for NEMT, and brokerages and their subcontractors that employ workers provide workers' compensation coverage. Medicaid provider enrollment with the Authority runs through the MMIS Provider Portal using only the forms OHA posts, with the step-by-step guide read first, and every enrolled provider is rescreened at least once every five years. The brokerage, not the Authority, holds your rates, so the enrollment packet and the subcontract are two different files.

• The client's name, the person who requested the ride on the client's behalf, and the client's OHP medical care identification numberOAR 410-136-3300 lists these among the elements the brokerage documents for every ride it provides or denies, so your trip record has to match them line for line.
• The pickup location and the destination, the date and time the ride was requested, and the mode of transport the brokerage authorized with its justification
• The subcontractor assigned to the ride and the date and time the brokerage notified it, which is the assignment each trip must tie back to
• Actual miles traveled from origin to destination on the most cost-effective route, regardless of the number of clients in the vehicleOAR 410-136-3220 pays actual miles on that route with a separate rate for shared rides, and CMS says drivers document loaded miles only, because a no-show is not a billable trip.
• The driver and vehicle on the trip and the times of pickup and drop-off as drivenCMS states that at a minimum all states require the beneficiary's name and Medicaid identifier, the pickup and drop-off locations, the date and time the service was furnished and the miles traveled with the beneficiary in the vehicle.

A base rate per mode from your subcontract, not a HCPCS table. OAR 410-136-3220 has the brokerage reimburse a subcontractor for the most cost-effective route from origin to destination that benefits the client's condition, at base rates negotiated between the brokerage and the subcontractor for each mode of transportation, for actual miles traveled regardless of how many clients were in the vehicle, with a different rate for shared-ride transports and no payment for waiting for a client to reach the vehicle or for helping a client in or out, apart from limited medical situations. This page lists no HCPCS codes or rates.⁷ The brokerage itself is paid by the Authority at a fixed rate per ride, direct plus indirect costs divided by projected monthly rides, settled annually, and under OAR 410-136-3200 it sends the Authority claims data files in the standardized electronic billing format the Authority prescribes after verifying client eligibility on the date of service. The claim format between you and the brokerage is whatever its subcontract specifies. Plain-language explanations of the transport codes and the origin and destination modifiers are on the NEMT billing codes page.

Twelve months for a fee-for-service claim to the Authority, under OAR 410-120-1300: Medicaid fee-for-service claims must be filed within 12 months of the date of service, a denied claim may be resubmitted within 18 months of the date of service, a claim that failed to cross over electronically from Medicare goes in on paper no later than six months after the date printed on the Medicare explanation of benefits, and a claim held up by departmental error may be filed up to six months after the error is discovered. Claims for CCO members follow OAR 410-141-3420.¹¹ Trips a brokerage arranges are billed to the brokerage under your subcontract, which sets its own submission terms; the twelve-month rule governs claims that go to the Authority itself.