NEMT billing in Texas

Split model: Medicaid managed care organizations are responsible for approving nonemergency medical transportation for their members, while HHSC's Medical Transportation Program (MTP) arranges and prior authorizes every fee-for-service trip, covering mass transit passes, demand response rides by taxi or wheelchair van, mileage for registered individual transportation participants, and meals, lodging and advance funds for clients 20 and younger.¹ The MTP handbook states that it does not apply to managed care. Under its HHSC contract, TMHP enrolls demand response transportation service (DRTS) providers and transportation network companies, registers individual transportation participants (ITPs) and processes MTP claims. The Medicaid Managed Care Handbook, cited below, lists MTP among the programs administered by TMHP or other state programs rather than by the client's MCO.

Medicaid provider enrollment in Texas runs through the Provider Enrollment and Management System¹¹. HHSC's Medical Transportation Program arranges and prior authorizes every fee-for-service trip, while Medicaid managed care organizations approve nonemergency transportation for their own members¹.

Two MTP provider types enroll directly with TMHP: demand response transportation service (DRTS) providers and transportation network companies (TNC). Individual transportation participants register with TMHP after a client's ride request but do not enroll as Medicaid providers; TMHP mails the registration package and, once it is processed, a letter with the Atypical Provider Identifier (API) and taxonomy code to use on mileage claims.¹ A newly enrolled MTP provider's claims must be received within 95 days of the date the NPI or API is issued and within 365 days of the date of service, and TMHP rejects every claim until the API exists. TMHP enrollment covers MTP claims only; a managed care member's trip is approved by the MCO, so the MCO or its vendor decides how you join its network.

• MTP prior authorization number for the trip, entered in block 23 of the CMS-1500 or the matching 837P fieldAll MTP services must be prior authorized by MTP, and claims without proper prior authorization are denied.
• Client name and 10-digit MPCN patient number exactly as printed on the MTP authorization form
• Date of service for each authorization, the quantity billed and the charge on each line
• A record showing that the level of service provided matches the level claimedHHSC and TMHP perform retrospective reviews that compare services billed to the client's record, and reimbursement is recouped when the record does not document the level billed.
• For ITP mileage, Form H3017 showing the date of the ride, miles authorized, MTP authorization number, client and ITP names, API and taxonomy code, signed by the ITP and by the doctor, dentist or drug store representative as proof the ride was takenIf any required item is missing the claim is denied. Medicaid providers must sign the client's H3017 or Form 3111, or give an equivalent statement on letterhead, and may not charge the client or TMHP for doing so.
• Prior authorization documents for clients 20 and younger, kept until HHSC gives notice that they may be destroyedThe handbook counts correspondence with HHSC or MTP, invoices, receipts, emails and electronic files as prior authorization documents.

Every MTP claim carries benefit code MTP, provider type MT, diagnosis code Z753, type of service 9, place of service 09 on paper or 99 in TexMedConnect, and taxonomy code 347C00000X. TMHP recommends T2003 with modifier U1, U2 or U3 for DRTS providers and transportation network companies, and S0215 for registered individual transportation participants.¹ The handbook's code table pairs DRTS claims with taxonomy 343800000X and TNC and ITP claims with 347C00000X. A modifier is placed after the five-digit procedure code. Trips paid by an MCO's vendor follow the vendor contract, not this table. For what each transport code and each origin and destination modifier means, in plain language, see the NEMT billing codes page.

95 days from the date of service for in-state providers and 365 days for out-of-state providers; a newly enrolled provider's claims must be received within 95 days of the date the NPI or API is issued and within 365 days of the date of service.¹ ITP mileage claims received more than 95 days after the ride are denied. Claims ready for disposition at the end of each week are paid or denied on the weekly Remittance and Status (R&S) Report, which is also available as an 835. An MCO vendor's window comes from your contract with it.