NEMT billing in South Carolina

Statewide broker. South Carolina's Medicaid state plan, as amended by SPA 22-0012 effective July 1, 2022, describes an NEMT Broker program whose broker processes and pays transportation providers for approved NEMT services, ensures providers comply with the broker contract's terms and conditions, monitors fraud and abuse with referrals to SCDHHS Program Integrity, runs quality assurance including corrective action plans and audits, and produces management and performance reports. The same amendment moved adult day health care transportation within 15 miles of the center to the NEMT broker.² Three services sit outside the broker program: emergency ambulance, covered fee-for-service for FFS members and by the managed care organizations for their enrollees; special needs transportation for designated populations provided by state agencies such as the School for the Deaf and Blind, the Department of Social Services, Continuum of Care and the Department of Education under contract with SCDHHS; and NEMT for nursing home residents, which nursing homes arrange and pay for from an NEMT component in their rates using any qualified transportation provider.

Modivcare is the statewide NEMT broker for South Carolina Healthy Connections Medicaid, and the state plan's NEMT Broker program places processing and paying transportation providers with the broker⁴.

Through the broker. The state plan makes the NEMT broker responsible for ensuring transportation providers comply with the broker contract's terms and conditions, so credentialing of your company, drivers and vehicles happens with Modivcare under its South Carolina contract. Modivcare's provider page describes field visits to confirm vehicles are up to contract standards, training programs specific to NEMT, and a Join Our Network contact form as the entry point. SCDHHS sets its own Healthy Connections provider enrollment requirements, which apply alongside broker credentialing.³ Modivcare's South Carolina facility page says that under the South Carolina DHHS contract, Medicaid transportation is arranged by Modivcare, and Absolute Total Care, one of the state's Medicaid health plans, tells its members that Healthy Connections partners with Modivcare for free rides, so a network provider's trips arrive through Modivcare's dispatch rather than from the member or the plan.

• Member's Healthy Connections Medicaid ID number as booked with ModivcareThe brochure lists the information Modivcare takes at booking; your Modivcare agreement sets the full trip record it expects before paying.
• Name and address of the medical provider or facility, and the appointment day and time
• Pickup time and location, and the trip's outcome, including a late pickup reported through Ride Assist or a cancellation given with 24 hours' notice
• For a hospital discharge, the reservation made by a facility representative, with a pickup time for an advance discharge or at least three hours' notice for a same-day discharge
• A Medical Necessity Form for any member who needs stretcher, Basic Life Support or Advanced Life Support level of serviceModivcare's South Carolina facility page lists the Medical Necessity Form, the Level of Service Form, standing order forms and mileage reimbursement trip logs among its downloads.

Trips Modivcare assigns are paid under your Modivcare agreement, and the state plan places processing and paying transportation providers with the broker, so the claim is Modivcare's trip record and rate terms rather than a HCPCS claim to SCDHHS. Modivcare's provider page describes web-based billing and online claim submission through its platform, with WellRyde offered as a digital dispatch platform.³ Nursing home residents' rides are billed to the facility under your arrangement with it, since the facility pays NEMT from its rate. Emergency ambulance claims follow SCDHHS fee-for-service or the member's managed care organization and are outside this page. For what each transport code and each origin and destination modifier means, in plain language, see the NEMT billing codes page.

Set by the Modivcare provider agreement. Neither the state plan pages nor Modivcare's public South Carolina materials publish a filing window for broker claims, so your agreement and Modivcare's claim rules govern, and the biller treats the completion date of each trip as the start of the clock.³ Modivcare's provider page says faster online claims submission speeds payment, and its brochure asks for 24 hours' notice of cancellations; neither states a payment cycle for South Carolina.