NEMT Medicaid Prior Authorization Verification

Verifies non-emergency medical transportation trip authorization, prior approval number, and Physician Certification Statement before service to reduce authorization-related claim denials.

Verification Summary

• Verification Date
  Date the authorization was verified.
• Verification Time
  Time the verification was completed.
• Verification Result
• Can service proceed?
  Select Yes only if the authorization, trip details, and required documentation are confirmed.
• Verification Notes
  Brief notes for the audit trail, including any mismatch, exception, or follow-up needed.

Member and Trip Details

• Member ID
  Medicaid member identifier used to match the authorization record.
• Member Initials
  Optional identifier if needed for internal matching. Avoid full name unless required by your workflow.
• Trip Date
  Requested date of transport.
• Trip Type
• Pickup Location Type
• Dropoff Location Type

Authorization Details

• Prior Approval Number
  Authorization or prior approval number issued by the payer.
• Payer Name
  Medicaid plan or payer responsible for the authorization.
• Authorization Start Date
• Authorization End Date
• Authorized Trip Count
  Number of trips approved under the authorization, if applicable.
• Remaining Trips
  Remaining approved trips available before this service.

Physician Certification Statement

• Is a Physician Certification Statement required?
• PCS on File
• PCS Date
  Date the PCS was signed or verified.
• PCS Expiration Date

Exceptions and Follow-Up

• Exception Type
• Follow-Up Owner
• Follow-Up Due Date
  Date by which the authorization issue should be resolved.
• Exception Details
  Describe the issue and any corrective action taken. Avoid unnecessary PII.

Submission Acknowledgment

• Submitter Name
  Name of the staff member completing the verification.
• Submitter Role
  Role or department of the staff member completing the verification.
• Acknowledgment