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Run: NEMT Medicaid Prior Authorization Verification

Verify NEMT Medicaid trip authorization, prior approval number, and Physician Certification Statement before dispatch so eligible rides move forward and avoi...

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Verification Summary

Verification Date (required)

Date the authorization was verified.

Verification Time (required)

Time the verification was completed.

Verification Result (required)

Can service proceed? (required)

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 (required)

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 (required)

Requested date of transport.

Trip Type (required)

Pickup Location Type (required)

Dropoff Location Type (required)

Authorization Details

Prior Approval Number (required)

Authorization or prior approval number issued by the payer.

Payer Name (required)

Medicaid plan or payer responsible for the authorization.

Authorization Start Date (required)

Authorization End Date (required)

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? (required)

PCS on File

PCS Date

Date the PCS was signed or verified.

PCS Expiration Date

Exceptions and Follow-Up

Exception Type (required)

Follow-Up Owner

Follow-Up Due Date

Date by which the authorization issue should be resolved.

Exception Details (required)

Describe the issue and any corrective action taken. Avoid unnecessary PII.

Submission Acknowledgment

Submitter Name (required)

Name of the staff member completing the verification.

Submitter Role (required)

Role or department of the staff member completing the verification.

Acknowledgment (required)

Yes No N/A

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