TL;DR
- A trip can be completed and still denied if the paperwork does not meet federal and state requirements.
- Federal auditors check whether the rider received a Medicaid-covered service on the date of transport, whether the provider and vehicle met state requirements, and whether the documentation supports the claim.
- An audit of Massachusetts found 86 of 100 sampled claim lines did not comply with federal and state requirements.
- An audit of Indiana found 18 of 120 sampled claims did not comply.
- Most of the information auditors look for is collected during the booking call, weeks before anyone submits a claim.
An NEMT trip has to pass two checks. The operational check covers whether the driver arrived, the rider reached the appointment, and the vehicle came back. The administrative check covers whether the claim matches what the payer authorized and whether the file holds the records the state requires.
A trip can pass the first check and fail the second. The provider has already paid for the fuel, the driver, and the vehicle, and the claim is denied.
What Auditors Actually Check
The HHS Office of Inspector General audits state NEMT programs, and the published reports list what the reviewers look at.
The first item on that list is about the rider rather than the vehicle or the driver. The rider has to have received a Medicaid-covered service on the day of the trip. If the appointment was cancelled after the rider arrived, or the destination is not a covered service, the claim can be denied for that reason alone.
OIG announced a new round of NEMT audits in May 2026, noting that prior authorization for these services generally must be supported by a medical practitioner’s order. These audits are ongoing.
| Audit | Sample | Claims that did not comply | Estimated improper payments |
|---|---|---|---|
| Massachusetts | 100 claim lines | 86 | At least $14 million |
| Indiana | 120 claims | 18 | $3.5 million |
Sources: OIG audit of Massachusetts, A-01-19-00004 and OIG audit of Indiana, A-05-18-00043.
Both audits covered claims paid between January 2016 and December 2017, so the figures are several years old. The Massachusetts sample was drawn from 896,792 lines of service for which the state paid $17.3 million. The Indiana sample came from 920,338 claims totalling $52.4 million.
Both audits reviewed state oversight rather than any single provider. The requirements they checked apply to every claim.
Eligibility Is Checked on the Day of the Trip
Medicaid eligibility can change from one month to the next. Auditors check eligibility against the date of the trip rather than the date the trip was booked.
Standing orders carry the most risk. The trip is booked once and then repeats for months, and the schedule does not change when a rider’s coverage ends.
Getting the details right on the call?
Pac Biz places trained NEMT phone agents who capture eligibility, authorization, and service level at booking, so trips reach billing with the information already recorded.
What Gets Missed on the Call
Most of the information an auditor asks for was available during the booking call. Four errors account for the majority of denials.
- The destination was not confirmed as a covered service. The rider gives an address and the agent books it. Whether that address is a Medicaid-covered medical service is a separate question, and it decides whether the claim is paid.
- Eligibility was checked at booking and not again. This affects standing orders more than any other trip type, since the booking happens once and the trips repeat for months.
- The authorization does not match the trip that ran. The authorization covers one mode of transport and the driver provided another, or the mileage went past what was approved.
- The insurance details contain an error. A wrong digit in a member ID or a date of birth is enough for a claim to come back.
Each of these is a question somebody has to ask while the rider is on the phone arranging the trip.
What to Check on Your Own Accounts
Confirm these five things on your own accounts:
- Whether your intake process verifies eligibility on the date of service rather than at the time of booking
- How often standing orders are re-verified against current coverage
- Whether your agents can tell from the destination alone whether a trip is covered
- Who obtains prior authorization, since in NEMT this usually falls to the provider or the broker rather than the ordering clinician
- How long your state requires records to be kept and where they are stored. Indiana requires providers to retain records for seven years from the date of service.
The Short Version
A claim is made from information collected during a phone call that happens way before the trip. If the eligibility check, the authorization, and the destination are recorded correctly on that call, the claim is usually paid. If any of them is wrong, the trip costs the same to run and the claim is denied.
Start by looking at your last month of denials and sorting them by cause. If most trace back to information captured at intake, the fix belongs on the phone rather than in billing.