Form 4214, Request for Non-Emergency Medical Transportation (NEMT) Services

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Effective Date: 2/2020


Updated: 2/2020


This document establishes a uniform process for managed care organizations (MCOs) to submit requests for non-emergency medical transportation (NEMT) services to:

  • the managed transportation organizations (MTO); or
  • full risk brokers (FRB) for members traveling beyond their MCO service area (SA) to a covered health care service.

MTP provides previously authorized NEMT services to and from covered health care services, based on medical necessity, and when no other means of transportation are available.

NEMT services includes various modes of transportation including demand response, intercity bus, commercial airfare, and mileage reimbursement for authorized Individual Transportation Participants (ITPs). In addition, NEMT services include meals and lodging to eligible Medicaid members ages birth to 20 years old and their attendants, as well as transportation for clients of the Children with Special Health Care Needs (CSHCN) Program and Indigent Cancer Patients (TICP) Program, when applicable.

Form 4214 is used to request long distance NEMT services for managed care Medicaid members including dual eligible Medicaid members. For the purposes of this form, “long distance” is defined as a trip beyond the member’s assigned SA.

When to Prepare:

  • The member contacts the MTO/FRB to request NEMT services for long distance travel;
  • The MTO requests Form 4214;
  • The member contacts the MCO and provides member and appointment information;
  • The MCO verifies the rendering provider is enrolled with Texas Medicaid Health Care Partnership (TMHP) and the location is included in the Combined Master Provider File (CMPF);
  • The MCO confirms appointment is an allowable Medicaid service;
  • The MCO completes and submits the Form 4214 to the assigned MTO/FRB; and
  • The MTO/FRB authorizes the NEMT Services.

Detailed Instructions:

All sections must be completed prior to submission to the MTO/FRB. Failure to complete all sections accurately may result in delayed processing of NEMT request.

Section I. Member’s MCO Information: Self-explanatory

Section II. Member Information: Self-explanatory

Section III. Medical and Appointment Information:

  • Appointment Date - Use calendar or enter the date of the member’s medical appointment.
    • Indicate whether the appointment is a Hospital Stay or Regular Appointment utilizing provided check boxes.
    • Choose date of discharge or check “unknown”.
  • Appointment Time - Enter the time of the member’s appointment.
  • Provider or Facility Name - Enter the rendering provider or facility name.
  • Provider or Facility Rendering National Provider Identifier (NPI) - Enter the rendering provider or facility NPI.
  • Provider or Facility Address - Enter the provider or facility address
  • Provider or Facility Phone Number - Enter the rendering provider or facility phone number.
  • Reason for Visit or Medical Services Treatment - Enter the reason for the medical appointment.
  • Attendant Required for Appointment - Check “Yes” or “No” to indicate if an attendant is required

Section IV-Special Instructions and Notes: Use this section to provide additional information not captured in Sections II and III. This includes, but is not limited to, language, special needs, and attendant request details.

Additionally, this section provides the MTO/FRB for the MCO to use with information on:

  • Adult Dental: If the service is for an adult member requiring transportation to and from a dental appointment, the MCO confirms that the member is HCBS STAR+PLUS and specifies the time that the member is eligible for dental services based on the most recent ISP. Do not send the ISP to the MTO
  • Distance greater than 150 miles one-way and 300 miles round trip: If the member is traveling more than 150 miles one-way and 300 miles round-trip, the MCO is required to document the reason that the member must travel the distance for covered health care services. This information must be documented by the MCO to support the long-distance travel.