Non-Emergent Medical Transportation Certification
This file contains the necessary information and form for requesting authorization for Non-Emergent Medical Transportation (NEMT) services. It is designed to assist healthcare providers in certifying member eligibility and the required mode of transportation. Ensure you fill out all fields accurately to avoid any delays in service authorization.
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How do I fill this out?
To fill out this form, gather all necessary member information, including medical limitations and duration of services required. Make sure to specify the mode of transportation needed based on the member's condition. Once complete, review all entries for accuracy before submitting.
How to fill out the Non-Emergent Medical Transportation Certification?
1
Gather the member's personal and medical information.
2
Document the member's limitations and required transportation mode.
3
Specify the anticipated start and end dates for services.
4
Sign the certification statement to confirm medical necessity.
5
Submit the completed form through the specified channels.
Who needs the Non-Emergent Medical Transportation Certification?
1
Healthcare providers requiring NEMT authorization for patients.
2
Members with medical conditions that impede their ability to use standard transportation.
3
Social workers assisting patients in securing transportation services.
4
Care coordinators managing the logistics of patient care.
5
Family members organizing transportation for relatives in need.
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1
Open the NEMT certification PDF in PrintFriendly.
2
Click on the edit icon to enter the editing mode.
3
Modify any fields needed, using the member's details.
4
Review all changes made to ensure accuracy.
5
Download the edited PDF to your device for submission.
What are the instructions for submitting this form?
To submit this form, you can use the Aetna Better Health of California secure provider web portal, available 24/7. Alternatively, fax the completed form to 1-844-584-4450 for San Diego or 1-866-489-7441 for Sacramento. You may also contact the UM Department by phone at 1-855-772-9076 for additional assistance.
What are the important dates for this form in 2024 and 2025?
For 2024, the NEMT certification form should be submitted no later than January 15, 2024, for services commencing in the new year. The same cutoff date applies for 2025 submissions. Timely submission ensures uninterrupted access to necessary transportation services.
What is the purpose of this form?
The purpose of this form is to facilitate access to Non-Emergent Medical Transportation services for members who require assistance due to medical or physical limitations. By completing and submitting this certification, healthcare providers can ensure that transportation needs are met efficiently and effectively. This process is essential for promoting access to care for individuals who may not be able to utilize conventional transport options.
Tell me about this form and its components and fields line-by-line.
- 1. Member Name: The full name of the member requesting transportation services.
- 2. Member DOB: The date of birth of the member.
- 3. Member ID #: The unique identification number assigned to the member.
- 4. Member Phone #: The contact number of the member.
- 5. Function Limitations Justification: Details about the member's physical and medical limitations.
- 6. Anticipated Duration: The expected length of time NEMT services will be needed.
- 7. Start Date: The date when the requested services should begin.
- 8. End Date: The date when the requested services should conclude.
- 9. Mode of Transportation Required: The type of transport needed based on the member's condition.
- 10. Requesting Provider Name: The name of the healthcare provider requesting the authorization.
- 11. Requesting Provider Signature: The signature of the provider indicating approval.
- 12. Date: The date when the request form is completed.
- 13. Provider Email: The email address of the requesting provider.
- 14. Provider Phone: The contact number of the requesting provider.
What happens if I fail to submit this form?
Failing to submit this form could result in delays in securing necessary transportation services for the member. It is crucial for ensuring access to medical care and appointments.
- Delayed Access to Care: Members may miss important medical appointments if transportation is not arranged timely.
- Increased Health Risks: Not receiving transport could exacerbate existing health conditions requiring urgent medical attention.
- Provider Coordination Issues: Healthcare providers may face challenges in coordinating care without timely transport.
How do I know when to use this form?
- 1. Medically Necessary Appointments: Members needing transportation to regular doctor visits.
- 2. Follow-Up Treatments: Patients requiring regular follow-up sessions for ongoing treatment.
- 3. Rehabilitation Services: Individuals attending therapy sessions who need assistance getting there.
- 4. Dialysis Sessions: Patients needing consistent transport for dialysis treatments.
- 5. Specialist Consultations: Members requiring transport for specialist visits who cannot drive themselves.
Frequently Asked Questions
What is the purpose of this form?
The form is used to request authorization for Non-Emergent Medical Transportation services for eligible members.
How do I submit the completed form?
You can submit the form online through the secure provider web portal, via fax, or by phone.
What information do I need to fill out?
You will need member information, medical limitations, the required transportation mode, and provider details.
How long is the authorization valid?
Authorization for NEMT services is valid for a maximum duration of 12 months.
What happens if the form is incomplete?
Incomplete forms may lead to delays in authorization and service delivery.
Can I edit the PDF after completing it?
Yes, you can edit the PDF using PrintFriendly before submitting.
Is there a specific format I must follow?
Make sure to fill out all required fields as specified in the form instructions.
How do I contact support for questions?
You can contact the UM Department at the provided phone number for assistance.
What modes of transportation are available?
Available modes include ambulance, litter van, wheelchair van, and air transport.
Who qualifies for NEMT services?
Members with medical conditions that restrict their ability to travel using standard transportation qualify for these services.
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