Non-Emergency Medical Transportation Trip Denial Process

It happens - sometimes Non-Emergency Medical Transportation (NEMT) trip requests get denied. When this happens, Medicare health plans are required to issue a Notice of Denial of Medical Coverage (or Payment), also known as an Integrated Denial Notice (IDN).

When and Why Members are Denied

Denials happen for several reasons, all related to eligibility. Some services that are not covered and therefore lead to trip denials, include:

• Transportation to and from a hospital
• Unable to verify service
• Members who are not eligible for Medicaid
• No prior authorization
• Facility shopping trips

Regardless of the reason, denials must be tracked and communicated, specifically:

• The reason for the denial
• Members must be alerted of the denial both informally (by phone) and formally (by letter)
• Members are given the opportunity to appeal the denial decision
• NEMT Brokers must be prepared to defend potential appeals by members who are denied

Software Makes the Trip Denials Process Easier

Appropriate non-emergency medical transportation software is essential for tracking and reporting denials activity. As soon as a member requests a trip, the first function of the software is to verify that the individual is eligible for transportation. Here's what happens:

• If rendered ineligible, the member's trip request is denied
• If eligible, the system proceeds to the next step in the process - booking a trip
• When booking, a member must provide basic information including their pickup location (origin), where they are going (destination), what time to arrive, mobility devices, and trip purpose
• There are a few particulars that require validation, including an approved destination address and an acceptable trip purpose (i.e. a trip to the hairdresser is not considered acceptable). If these are not allowed per the member's health plan requirements, then the trip request gets denied

Why Record Keeping Is Important

Being able to correctly document member denial reasons and refer to those decisions for reporting purposes is important. Additionally, if a member appeals the denial decision, a detailed record of the denial information (and justification) is stored by the software for easy reference. Finally, reporting of not just the number of denied trips but the reasons for those denials, is important to ensure denials are reasonably and equitably applied among members.