NEMT billing in Washington

Regional broker model. Washington established a brokerage for Medicaid non-emergency medical transportation in 1989, and HCA contracts with six transportation brokers that serve 13 geographic regions and cover all 39 counties, each one arranging rides for Apple Health clients in its own counties.² WAC 182-546-5300 covers managed care enrollees through the same brokers as fee-for-service clients, and WAC 182-546-5200 requires each broker to hold subcontracts with transportation providers in order for the providers to be paid, to select the lowest-cost available mode that is both accessible to the client and appropriate to the client's condition, and to set the level of assistance for each authorized trip, from curb-to-curb to hand-to-hand. HCA's program page says the brokers are held to performance-based contracts.

Medicaid provider enrollment in Washington runs through ProviderOne⁸. HCA's NEMT brokers contract directly with transportation service providers, so a Washington operator contracts with the regional broker for the counties it wants to serve and is paid by that broker rather than billing HCA for the trip².

Contract with the broker for your counties. HCA's NEMT 101 says the brokers contract directly with transportation service providers and tells a prospective provider to contact the regional broker responsible for the counties where it wants to do business. Under WAC 182-546-5200 the broker and its subcontracted transportation providers must be licensed, equipped and operated in accordance with federal, state and local law and the terms of their contracts, the broker screens its subcontracted providers and their employees against the federal exclusion lists before contracting and on an ongoing basis afterwards, and a provider is paid by the broker only under a subcontract with it.² HCA's sample broker contract sets the floor for every subcontract: drivers hold a valid driver's license, an abstract of driving record and insurance before serving clients; a new driver or volunteer clears a fingerprint-based Washington State Patrol criminal history check, repeated every three years with a WATCH report in the intermediate years, qualifying them for unsupervised access to children and vulnerable adults; the broker keeps records on each subcontractor's business licenses, certifications, insurance, driver verifications and vehicle inspections; and the subcontract gives the broker access to the provider's records for six years after it ends.

• The broker's authorization for the trip, obtained before the client travels, or the retroactive authorization requested within two business days of an after-hours urgent care or hospital discharge transportWAC 182-546-6000 makes every non-ambulance trip subject to prior authorization by the broker, and WAC 182-546-5200 tells the provider to follow the broker's after-hours instructions when the broker is closed; the broker then documents the reason for a retroactive authorization in the client's trip record.
• The client's name and ProviderOne services card number, the pickup point and drop-off point the broker authorized, and the date and time of each one-way tripCMS 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 number of miles traveled with the beneficiary in the vehicle. A trip under WAC 182-546-5100 is one-way transportation from the pickup point to the drop-off point.
• Loaded miles between the authorized points only, because the agency pays nothing for intermediate stops or delays that are not directly related to the approved trip
• The mode and the level of assistance the broker set for the trip, curb-to-curb, door-to-door, door-through-door or hand-to-hand
• A note for every no-show and cancellation, since brokers report no-shows where the provider attempted the pickup to HCA each month and verify a sample of completed trips after the factThe sample broker contract requires a documented post-trip verification review on at least one trip in ten, and a biennial desk audit of ten randomly selected trips per subcontractor covering documentation, timeliness, coding and medical justification, with a site visit every other year to confirm the security of client files and manifests.
• Driver and vehicle files the broker can produce at that audit: license, driving record abstract, insurance, background check dates and vehicle inspection records

No HCPCS claim goes to HCA for a brokered trip. A transportation provider is paid by its broker under the subcontract, which sets the rates and the submission format, and the sample broker contract bars a subcontractor from seeking payment from HCA, from the client or from any other contract service provider for a subcontracted trip. The unit the rule and the contract recognize is the trip, one-way from the pickup point to the drop-off point, with meals, lodging, parking, tolls and ferry fees as separate units the broker authorizes.⁵ HCA publishes separate billing guides and fee schedules for ambulance transportation on its provider billing guides page, for ambulance providers that bill ProviderOne directly; the rule lets a broker subcontract with licensed ambulance providers for non-emergency ground ambulance trips, which are then paid by the broker too. Plain-language explanations of the transport codes and the origin and destination modifiers are on the NEMT billing codes page.

The broker's subcontract sets the deadline for submitting a trip for payment, and HCA's sample broker contract requires the broker to pay its subcontractors within ten calendar days of receiving HCA's reimbursement for allowed trips. HCA's own limit in WAC 182-502-0150, 365 calendar days from the date of service for a claim to reach the agency and be assigned a transaction control number, governs claims billed to the agency, which brokered trips are not.⁵ A client's own request for reimbursement of a preauthorized trip, meal or lodging must reach the broker within 30 calendar days after the appointment, and after delayed certification or retroactive eligibility a request must be made within 60 calendar days of the eligibility notice and no later than eight months after the date of service.