How Florida NEMT providers contract, credential, and bill with Medicaid MCOs

What to take away

How Florida Medicaid managed care organizations buy NEMT

Florida runs Medicaid through managed care — the Statewide Medicaid Managed Care (SMMC) program, administered by the Agency for Health Care Administration (AHCA) under Part IV of Chapter 409, Florida Statutes. The state pays the plan a capitated rate, and the plan buys the ride. Price your work against the plan's rate sheet, never against a state fee schedule, because there is not one for you to bill.

Plans buy transportation two ways. Some keep an in-house transportation department. Others subcontract to a statewide or regional NEMT broker such as Modivcare or MTM. Which model a plan uses decides who signs your contract, who sets the rate, and who pays your claims.

Sunshine Health and Simply Healthcare are among the largest plans in the state, alongside WellCare of Florida, Humana Medical Plan, Molina Healthcare of Florida, and UnitedHealthcare Community Plan. They cover ambulatory, wheelchair, and stretcher transport, and they require prior authorization for most non-urgent trips. Companion rides are covered under narrower rules than the member ride itself.

Federal policy reaches into your denials. CMS publishes transmittals that change what states must cover and how they bill, so read Transmittals | CMS when a plan cites federal authority in a denial letter.

Members who ride public transportation hold rights under federal disability law. The Americans with Disabilities Act Title II Regulations | ADA.gov set the standard for public entity transportation, and plans copy parts of it into their NEMT manuals.

Market share decides whether a contract is worth the paperwork. A plan with deep membership in your county can fill your schedule. A small plan in the same county may not repay the cost of credentialing. Pick two or three plans and go deep rather than wide.

Contracting with Sunshine Health and Simply Healthcare

Start on the plan's provider services page, not with a cold call. Sunshine Health, Simply Healthcare, and the other Florida Medicaid plans publish network participation steps and a provider inquiry form on their provider websites. Submit the form, then call within a week and ask for the network development contact by name.

Expect a network adequacy review. Plans must show enough providers in each county, so a provider in a thin county has room to negotiate. State your counties, your vehicle count, and how many trips per day you can actually cover.

A typical sequence runs like this.

Read the agreement before you sign it. Payment terms, the plan's right to deny a trip after the fact, and termination notice are where disputes start. Packaging your nemt services packages before the rate conversation gives the plan something concrete to buy.

If the plan uses a broker, you may sign two contracts, one with the plan and one with the broker. Ask who holds the risk when a member no-shows or cancels at the curb.

Exclusivity clauses matter more than rate. Some agreements bar you from working with competing plans in the same county. That clause can cost more than the contract pays.

Credentialing requirements for Florida NEMT providers

Credentialing is where new providers stall. The plan verifies your business, your drivers, and your vehicles before a single claim pays, and a missing document stops the whole file.

Business-level items come first: active Florida Medicaid provider enrollment through AHCA, a Type 2 NPI, a current CAQH ProView profile, general liability and commercial auto insurance, and workers compensation coverage or a valid exemption.

Driver-level items come next: a valid Florida license, a clean motor vehicle record, a background check, CPR and first aid certification where the plan requires it, and a passed drug screen.

Vehicle-level items close it out: registration, inspection records, wheelchair securement documentation where it applies, and proof of insurance naming the plan or broker as required.

Plan-specific paperwork sits on top of that common file. Start with AHCA: state Medicaid provider enrollment is a separate application from plan credentialing, and the plans check it before they load you. Sunshine Health and Simply Healthcare each issue their own credentialing application and attestation, and each asks you to authorize release of your CAQH ProView data. Complete the plan packet and the CAQH authorization in the same week, or the file sits idle.

Keep a compliance checklist for every driver and vehicle file, and update it before each recredentialing cycle. Recredentialing often runs on a three-year cycle. Calendar it, because a lapsed file can stop claims without warning and reinstatement takes weeks.

HIPAA training records are part of the packet. Plans ask for proof that staff who touch member data have been trained, and they may audit those records. Confirm the current requirement with the plan and with your own counsel.

Billing and claims submission to Florida MCOs

Billing starts with eligibility. Check the member's plan and eligibility on the date of service, every time. A trip for a member who switched plans last week is a denial waiting to happen.

Get prior authorization before the trip, not after. Most Florida plans require it for non-urgent transport, and some require it for recurring dialysis or therapy runs. Store the authorization number with the trip record.

Code correctly. NEMT claims use HCPCS and CPT codes for vehicle type and mileage — A0130 for a wheelchair van trip, A0428 with A0425 for non-emergency basic life support transport and loaded mileage, and the T2000 series (T2001 non-ambulance, T2002 per mile, T2003 per trip) for other non-emergency rides — plus the modifiers your plan's companion guide lists for waiting time or extra attendants. A code that does not match the service is a top denial cause.

Submit through the plan's portal or clearinghouse. Each plan has its own payer ID, companion guide, and timely filing limit; download the companion guide and note the payer ID before your first claim, and track the limit per plan, in days from date of service. Sunshine Health and Simply Healthcare both run provider portals where you can check eligibility and claim status.

A clean claim needs the trip log, the signed proof of delivery, the authorization number, and the driver and vehicle identifiers. Attach what the plan asks for on the first submission rather than on appeal.

Payment timelines vary by plan and contract. Federal Medicaid managed care rules at 42 CFR Part 438 govern what every MCO contract must include, so the prompt-payment terms you get are the ones written into your agreement. Read the prompt-payment clause, and reconcile every remittance advice against the trips you ran. When you price new work, use a quote template that separates base rate, mileage, and wait time.

Storm season disrupts billing as well as driving. A closed office, a flooded road, or a plan's own claims backlog can push you past a timely filing limit, so ask each plan for its disaster and billing-continuity instructions before hurricane season, and document every trip you run under an emergency declaration.

Keep the trip documentation even when a storm shuts you down. AHCA and the plans may suspend prior authorization and extend filing deadlines for affected counties during a declared emergency, and those notices are your authority to bill late. Members displaced by a declared disaster find their own help through Get Assistance After a Disaster | FEMA.gov.

Common denial reasons and how to prevent them

Denials are predictable, and most fall into six categories. Each has a front-end fix that costs less than the appeal.

Appeal fast. Most plans give a short window, and a clean packet with the trip log and authorization resolves many denials on the first pass. Write your proposal template and your appeal letters the same way: facts, dates, and the exact clause you are citing.

What a Florida MCO contract actually pays for

A rate sheet is a list of trip types, not a promise of margin. Ambulatory, wheelchair, stretcher, and mileage each carry a different rate, and the rate itself is negotiated county by county and plan by plan; no public fee schedule sets it for NEMT. The mix you accept decides whether the contract works.

Run the arithmetic on your own numbers. Take the plan rate for the trip type, subtract loaded and empty miles at your cost per mile, subtract the driver hour including wait time, and subtract the authorization and billing labor. What remains is your contribution per trip. If it is thin, no volume fixes it.

Empty miles are the quiet killer in Florida. A wheelchair trip from a rural county to a specialty appointment in Tampa or Gainesville can pay well and still lose money on the return leg. Ask the plan whether it pays a deadhead or minimum mileage charge.

No-show and cancellation fees are negotiable and worth more than a small rate increase. A route of eight trips that loses two to no-shows needs either a fee or a shorter cancellation window.

Volume commitments cut both ways. A plan that guarantees trips per day lets you justify a second vehicle. A plan that guarantees nothing leaves you holding equipment cost per available day with no offsetting revenue.

Common questions

Do I need a contract with every Florida Medicaid plan?

No. You can contract with one plan or several. Most new providers start with one or two plans in their county and add more once billing runs clean.

How long does credentialing take with Sunshine Health or Simply Healthcare?

It varies by plan and by how complete your packet is. Expect several weeks to a few months, and expect delays whenever a document is missing or expired.

Can I bill for a trip without prior authorization?

Usually not for non-urgent transport. Some plans allow retroactive authorization in limited cases, but treat prior authorization as a requirement before the trip. Confirm the rule in your provider manual.

What happens if a member is not eligible on the date of service?

The claim will deny. Check eligibility on the day of the trip, and if the member has moved to another plan, bill that plan instead.