OAR 410-136-3020
General Requirements for NEMT

(1)

The Authority may enroll governmental transportation brokerages (local units of government) or other entities to arrange rides and pay subcontractors for NEMT services. The Authority may limit the enrollment with brokerages to units of local government.

(2)

For purposes of the rules (OAR 410-136-3000 (Responsibility for Providing Non-emergent Medical Transportation) through 410-136-3360 (Discontinuation of Brokerage as Enrolled Provider)), “subcontractor” means the individual or entity with which the brokerage subcontracts or employs to drive the client to and from OHP covered medical services.

(3)

The brokerage shall:

(a)

Prior authorize and pay subcontractors for the least costly but most appropriate mode of transport for the client’s medical needs to and from an OHP covered medical service. The most appropriate and least costly ride may include requiring the client to share the ride with other clients;

(b)

Verify that the client is obtaining OHP covered medical services in the client’s local area. “Local area” means an area within the accepted community standard and includes the client’s metropolitan area, city, or town of residence;

(c)

Verify the client’s OHP eligibility and that the client’s benefit package includes NEMT services. The brokerage shall verify this through electronic eligibility information;

(d)

Assess the client’s access to other means of transportation, such as driving their own car or getting a ride from a family member or neighbor;

(e)

Verify the client’s attendance for continuing requests for rides if the medical provider could not affirm an appointment for a previous ride;

(f)

Schedule a ride with an alternate subcontractor if the subcontractor originally assigned is unable to provide the ride; and

(g)

Assign rides based on an evaluation of several factors including, but not limited to:

(A)

Cost;

(B)

The client’s need for appropriate equipment and transportation;

(C)

Any factors related to a subcontractor’s capabilities, availability, and past performance; and

(D)

Any factors related to the brokerage’s need to maintain sufficient service capacity to meet client needs.

(4)

Pursuant to OAR 410-120-1210 (Medical Assistance Benefit Packages and Delivery System), Medical Assistance Benefit Packages and Delivery System, clients receiving the following benefit packages are not eligible for NEMT:

(a)

Citizen Alien Waived Emergency Medical (CWM); and

(b)

Qualified Medicare Beneficiary (QMB) only.

(5)

The brokerage shall maintain records of the reasons for authorizing a ride:

(a)

That is not cost effective or not based on the factors specified in section (3);

(b)

With more than two attendants for an ambulance or stretcher car; or

(c)

With more than one attendant for a wheelchair van.

(6)

The brokerage shall provide a ride to a client to fill prescription medication only in the following situation:

(a)

The client needs to stop on the way home to fill or pick up prescribed medication related to the medical service for which the brokerage provided the ride;

(b)

It is medically necessary to fill or pick up the medication immediately; and

(c)

The pharmacy is located on the return route or is the closest pharmacy to the return route.

(7)

The brokerage may provide a ride to a client to fill prescribed medication under the following situations:

(a)

The brokerage asks the client if the prescription service is available through the Authority’s contracted postal prescription service, and the client responds that it is not available through that source;

(b)

The client has an urgent need to fill or pick up prescribed medication because the postal prescription service mailed the wrong medication, or the client has an unexpected problem caused by the medication; or

(c)

The client is transient or without regular access to a mailbox. In this situation, the brokerage may evaluate the need on a case-by-case basis.

(8)

The brokerage shall provide rides outside the brokerage’s service area, as described in Table 136-3380, under the following circumstances:

(a)

The client is receiving an OHP covered medical service that is not available in the service or local area but is available in another area of the state;

(b)

The client is receiving a covered service in California, Idaho, or Washington where the service location is no more than 75 miles from the Oregon border; or

(c)

No local medical provider or facility will provide OHP covered medical services for the client.

(9)

Brokerages may coordinate to provide a return ride to a client who receives medical services outside the client’s local area.

(10)

Brokerages shall retroactively authorize and pay for NEMT services that have already occurred only when the brokerage could not prior authorize the service because the brokerage was closed, and the request for authorization is within 30 days of the date of service. The brokerage also must confirm that one of the following circumstances supported the ride:

(a)

The eligible client needed urgent medical care;

(b)

The eligible client required secured transport pursuant to OAR 410-136-3120 (Secured Transports), Secured Transports; or

(c)

The client was in a hospital, and the hospital discharged or transferred the client.

(11)

Notwithstanding section (10), a brokerage shall retroactively authorize NEMT services for ambulance transports when:

(a)

An ambulance provider responds to an emergency call, but the client’s medical condition does not warrant an emergency transport;

(b)

The ambulance provider transports the client as a NEMT service; and

(c)

The ambulance provider requests retroactive authorization within 30 days of the NEMT service.

(12)

Brokerages shall not authorize or pay for rides outside their service areas based only on client preference or convenience.

(13)

Brokerages shall provide toll-free call centers for clients to request rides. The following pertain to the brokerage’s call center and scheduling of rides:

(a)

The call center shall operate at a minimum Monday through Friday from 9:00 a.m. to 5:00 p.m., but the brokerage may close the call center on New Year’s Day, Memorial Day, July 4, Labor Day, Thanksgiving, and Christmas. The Authority may approve, in writing, additional days of closure if the brokerage requests the closure at least 30 days in advance.

(b)

Brokerages shall make all reasonable efforts for clients to have access to available NEMT services 24 hours a day. When the call center is closed, the brokerages shall provide a recording or answering service to refer the client directly to a subcontractor. If no subcontractor is available, the brokerage must provide clients with recorded information about service hours and how to reach emergency services by calling 911;

(c)

The brokerage shall allow a client to schedule rides at least 30 days in advance of the medical service; and

(d)

The brokerage shall allow a client to request multiple ride requests at one time.

(e)

The brokerage shall develop procedures and make reasonable efforts to arrange a ride requested on the day of the medical service when the medical service is:

(A)

For an urgent medical condition; and

(B)

Due to the urgency of the medical condition, the client scheduled an immediate medical appointment.

(14)

The brokerage is not responsible for providing emergency medical transportation services. However, brokerages shall have procedures for referring clients requesting emergency medical transportation services to the appropriate emergency transportation resources and procedures for subcontractors per OAR 410-136-3040 (Vehicle Equipment and Subcontractor Standards), Vehicle Equipment and Subcontractor Standards.

(15)

The Authority shall collaborate with brokerages and CCOs to develop and conduct a statewide client satisfaction survey at least once every two years. The Authority may contract with one or more brokerages to conduct the survey. The Authority shall use the results of the survey to identify and address potential operational deficiencies and to identify and share successes in the NEMT program.

(16)

Brokerages shall establish regional advisory groups consisting of representatives from the Authority, DHS, Area Agencies on Aging, consumers, representatives of client advocacy groups from within the service or local area, brokerage subcontractors, and providers of NEMT ambulance services. The role of the group includes, but is not limited to:

(a)

Assisting in monitoring and evaluating the NEMT program; and

(b)

Recommending potential policy or procedure changes and program improvements to brokerages and the Authority and assisting in prioritizing those changes and improvements.

(17)

Brokerages shall have the discretion to use or not use DHS-approved volunteers. DHS shall provide brokerages with a list of approved and trained volunteers. DHS shall supervise the volunteers and assumes all liability for each volunteer as provided by law.

(18)

Brokerages or their subcontractors shall not bill eligible clients for any transports to and from OHP covered medical services or any transports where the Authority denied reimbursement.

(19)

On a minimum of five percent of the ride requests, brokerages shall contact medical providers to verify appointments and that the appointments are for OHP covered medical services.

(20)

Brokerages may purchase tickets for common carrier transportation, such as inter- or intra-city bus, train, or commercial airline when deemed cost effective and safe for the client.

Source: Rule 410-136-3020 — General Requirements for NEMT, https://secure.­sos.­state.­or.­us/oard/view.­action?ruleNumber=410-136-3020.

Last Updated

Jun. 8, 2021

Rule 410-136-3020’s source at or​.us