Authorizations 101

An insurance authorization, often simply referred to as just an “authorization”, is a formal review and approval process to determine if a non-emergency medical transportation (NEMT) service is covered under the rider’s health insurance plan. It is important to note that authorizations are not a guarantee of payment but rather an initial confirmation that the service is medically necessary and meets the plan’s criteria for a covered service.

If a booking organization has authorizations by Roundtrip in scope, Roundtrip will attempt to obtain the authorization for the requested ride. Within Roundtrip, a rider’s insurance plan can only be selected as the payer for medical sedan, wheelchair van, stretcher van, and ambulance level transports.

Depending on the vehicle type, plan type, plan requirements, and booking organization’s configurations, the method to obtain the authorization may vary. Once a ride is successfully authorized, it is still the assigned Transportation Provider’s responsibility to follow all billing and documentation requirements for the rider’s health plan in order to submit a claim for payment.

Medicare is a U.S. federal health insurance program primarily for people aged 65 and older, though it also covers certain younger individuals with disabilities and people with End-Stage Renal Disease (ESRD). Medicare consists of several parts:

Depending on an rider’s Medicare plan, their level of coverage (i.e. which parts of Medicare they are eligible for) can vary. For example, an individual may have Part A only while another individual has both Parts A and B. Many individuals with Original (i.e. Generic) Medicare also choose to opt into "Supplemental" or "Medigap" plans to help cover the cost of what their Original Medicare plan does not cover.

When it comes to authorizations, coverage and the authorization process can vary for the different flavors of Medicare plans: Original Medicare, Medicare Dual Plans, and Medicare Advantage plans. How authorizations are obtained and the transportation that is covered can vary by plan:

Medicaid is a government-funded health insurance program that provides medical coverage to eligible low-income individuals and their families. It is jointly funded by federal and state governments and administered at the state level, offering services such as doctor visits, hospital care, and non-emergency medical transportation. Eligibility and covered services may vary by state. In addition, some states may also have their own names for Medicaid (i.e. Medicaid is referred to as "Medi-Cal" in the state of California).

When it comes to authorizations, transportation must be arranged with a broker when a Medicaid plan is selected as the payer. A broker is a third-party organization contracted by a state’s Medicaid program or managed Medicaid plan to coordinate transportation services for eligible members. Brokers can vary state by state and plan by plan - for example, some states may have a single broker for all Medicaid plans, while other states may have multiple brokers that are contracted for each Medicaid plan offered.

There are a few flavors of Medicaid plans that riders may have coverage under:

Private insurance refers to any insurance plans that are not administered under Medicare or Medicaid. These are typically plans that are paid for by the rider or their family through their employer or through an insurance marketplace. Coverage can vary widely for private insurance plans - for example the same plan name may have dozens, if not hundreds, of configurations with varying degrees of coverage. For example, Blue Cross Blue Shield Gold Plan may have HMO, POS, and PPO plans, all with different coverages.