NEMT Broker Trip Authorization Verification

Inspection template for verifying broker-assigned non-emergency medical transportation trip details, level of service, and authorization against the manifest before dispatch. Designed to catch eligibility, service-level, and wheelchair-versus-ambulatory coding errors before the vehicle departs.

Inspection Setup and Trip Identification

• Trip identifier, date, and scheduled pickup time match the manifest record
• Member name or unique member identifier matches the broker authorization record
• Origin and destination addresses match the authorized trip details
• Broker name and authorization reference number are present and legible
• Verification completed before vehicle dispatch

Authorization and Eligibility Verification

• Authorization is active for the scheduled date and time window
• Member eligibility was verified against the applicable broker or payer source
• Trip authorization covers the requested one-way or round-trip service
• Any trip limits, mileage limits, or time restrictions are within authorized parameters
• Any broker notes, special instructions, or prior approval requirements were reviewed

Level of Service and Mobility Coding

• Authorized level of service matches the manifest coding
• Wheelchair-versus-ambulatory coding matches the broker authorization
• Any attendant, escort, or additional rider authorization is documented
• Vehicle type assigned is appropriate for the authorized level of service
• Any special equipment requirement is reflected in the manifest

Manifest Detail Reconciliation

• Pickup location, destination, and appointment time are consistent across documents
• Trip status, trip count, and leg sequence match the authorized service
• Any same-day changes, reroutes, or updated instructions are documented and approved
• No duplicate, overlapping, or conflicting trip assignment is present
• Manifest notes clearly identify any exception or hold status

Exceptions, Deficiencies, and Corrective Action

• Any deficiency identified during verification was documented
• Dispatch was held or escalated when authorization could not be confirmed
• Corrective action or broker follow-up was recorded for the exception
• Inspector comment summarizes the discrepancy and resolution

Closeout and Sign-Off

• Verification completed with no unresolved non-conformance
• Inspector name and signature
• Verification timestamp