What criteria will Medi-Cal consultants use to identify excluded services when NEMT is requested?
Medi-Cal consultants will verify the beneficiary is a member of an exempt group and will adjudicate the TAR according to the medical necessity of the service. If the beneficiary is not a member of an exempt group and the provider does not use a modifier to indicate an exemption, then the TAR will be denied. For an electronic Treatment Authorization Request (eTAR), this will occur at the point of entry. For a TAR form, this will occur at the field office screening point. In addition, if the NEMT will be used to obtain dental services, you may be required to submit a copy of an approve Denti-Cal authorization together with the TAR as part of medical necessity criteria. Example: a dental treatment precedent to a covered medical/surgical service.
