NC Medicaid Non-Emergency Medical Transportation (NEMT) Provider Broker Attestation Form Now Available

NCTracks now requires certain transportation services (taxonomy codes 343800000X, 343900000X, 344600000X, 347B00000X, 347C00000X, 347D00000X and 347E00000X) to complete a form to attest that they are an NEMT provider/broker. The NC Medicaid Non-Emergency Medical Transportation (NEMT) Provider/Broker Attestation Form may be downloaded from the Provider Policies, Manuals, Guidelines and Forms page under Provider Forms.

Providers must complete this form and upload it on the Upload Documents page when completing an Initial Re-verification, Enrollment, Re-enrollment Application, or Manage Change Request (MCR). The attestation must be signed by the Office Administrator (OA).

Please review the full respective requirements for each taxonomy below. A complete list of enrollment requirements by provider type may also be found in the Provider Permission Matrix (PPM) located under Quick Links on the Provider Enrollment page.

 

343800000X - Secured Medical Transport (VAN)

The provider must provide a signed attestation on letterhead confirming: a) all individuals on staff are trained to work with patients in crisis situations resulting from mental or emotional illness and/or substance abuse and b) will keep this training ongoing annually and for incoming staff. The provider must also provide proof of vehicle insurance for all registered vans. 

 

343900000X - Non-emergency Medical Transport (Van)

DSS will certify the agencies and prior approves each service.

 

344600000X -Taxi (Non-Emergency Medical Transport - Taxi)

The provider must provide proof of all vehicles meeting local, county, or state regulations in the jurisdiction where it is located. Valid vehicle registration(s) may serve as proof.  

 

347B00000X - Bus (Non-Emergency Medical Transport - Bus)

The provider must submit their current NC business license as a bus service.

 

347C00000X - Private Vehicle (Non-Emergency Medical Transport - Private Vehicle)

The provider must provide proof of vehicle insurance for all registered vehicle(s) in the individual provider's name and proof of current registration for all vehicles.          

       

347D00000X - Train (Non-Emergency Medical Transport - Train) 

The provider must submit their current NC business license as a train service.  

                               

347E00000X - Transportation Broker

The provider must submit proof to show they are contracted with the Pre-paid Health Plans (PHP).