TRANSPORTATION REIMBURSEMENT FORM INSTRUCTIONS

TRANSPORTATION REIMBURSEMENT FORM
INSTRUCTIONS FOR COMPLETION
PAYEE INFORMATION:
Key Name:
Print the Key Name, received upon enrollment. If you do have a key name or have not enrolled, contact
Provider Services at 1-866-769-3085.
Resource Number:
Print the assigned Resource Number, received upon enrollment. If you do not have a Resource Number or
have not been enrolled, contact Provider Services at 1-866-769-3085.
Payee Name:
Print the first and last name, full mailing address, physical address (if different than mailing) and telephone
number of the person to receive the payment.
Relationship to the Member:
Check the box that applies to your relationship to the member.
MEMBER INFORMATION:
Print up to the first three (3) letters of the first/last name of the member.
Print the member’s identification number on their New Hampshire Healthy Families card.
First/Last name:
Medicaid ID #:
TRIP INFORMATION: Identify trip information, COMPLETE ONE SIDE– NOT BOTH. The Payee is:
Self or Parent/Household Member (Transporting
Member)
A Volunteer
From:
From:
Print up to the first eight (8) letters of the
member’s hometown or city, and zip code.
Print up to the first eight (8) letters of the
provider’s town or city, and state.
To:
To:
To:
Print up to the first eight (8) letters of the volunteer’s
hometown or city, and zip code.
Print up to the first eight (8) letters of the member’s
hometown or city and zip code.
Print up to the first eight (8) letters of the provider’s town
or city and state.
One Way/Round Trip:
Check whether the trip was one way or round trip (Round trip means transport occurred to the
provider and returned the member to his/her home).
Total Miles per Trip:
Enter the number of miles traveled on the trip date. For volunteers, total miles include mileage from
home to pick up the member, plus the one way or round trip mileage.
Provider Name & Facility Group:
Print the name of the service providers, last name then first name order.
EXAMPLE: SMITH, JOHN; ABC PEDIATRICS
Address of Provider:
Print the street address including the town/city and state where services were rendered.
Provider Type Code:
Carefully print the Provider Type Code from the list in the shaded area that appears on the form. Note
some limitations apply. All specialist must include a code “6.”
Trip Date:
Print the month, day, and year for the service, this should be the same day in which the transportation
was provided.
CPT/CDT:
The Transportation Coordinator may request that the provider’s office enter the corresponding to the
services rendered to validate coverage.
Provider Signature:
The member/patient, or their authorized representative, is responsible for obtaining the provider’s
signature on this claims form at the time of service. The medical provider or a member of his/her
staff must sign and date the form on the same day that transportation was provided. If the
provider is using a signature staff both copies must be stamped. The provider may be a pharmacist.
Member Signature and Date:
The member must sign and date the form. If the recipient is a minor, the parent or legal
guardian must sign and date on his/her behalf.
Payee Signature and Date:
The payee must sign and date the form upon its completion.
PROCESSING INFORMATION: Claims must be received to New Hampshire Healthy Families’ mileage reimbursement team
within 90 days of the date of service on the claim. No reimbursement will be made for claims received after 90 days from the trip
date. FOR PAYMENT: Fax or e-mail and mail a hard copy of the completed form to the locations indicated below
Check the status of your reimbursement by calling 1-866-874-0222.
Mail
Fax or e-mail
2500 Abbott Place Attn: Reimbursement Team, St. Louis, MO 63143
314-951-7475 or [email protected]
TRANSPORTATION REIMBURSEMENT FORM
*** INSTRUCTIONS ON THE BACK OF THE FORM***
PAYEE/RESOURCE INFORMATION
Key Name: _______ ______ ___
Resource #:
Payee Name (Enrolled Driver) and Address:
Enrolled Driver License Number:
Insurance Carrier:
Policy #:
First
Last
Mailing Address
Physical Address (If different than Mailing)
City/Town
(
)
Telephone #
State
Relationship to Member:
Service Code:
(MT) Member
Self
Transporter
Parent or Household Member
(VT) Volunteer
Volunteer
Transporter
Zip Code
MEMBER INFORMATION (Person receiving transportation services)
___ ___ ___
___ ___ ___
Member First Name (1st 3 only )
Member Last Name (1st 3 only)
TRIP INFORMATION
Recipient Transporter
From:
___ ___ ___ ___ ___ ___ ___ ___
Member’s Home Town/City
To:
___ ___ ___ ___ ___ ___ ___ ___
Providers Town/City
1.
One Way Trip
2.
Round Trip
______________ __ __ __ __
___ ___ ______ ___ ______ ___ ______ ___ ___
Member’s Medicaid ID Number
Volunteer Transporter
From:
___ ___ ___ ___ ___ ___ ___ ___
Volunteer Home Town/City
To:
___ ___ ___ ___ ___ ___ ___ ___
Member’s Home Town/City
___ ___ ___ ___ ___ ___ ___ ___
Provider’s Town/City
___ ___ ___ ___ ___
Zip Code
OR
___ ___
State
___ ___ ___ ___ ___
Zip Code
___ ___ ___ ___ ___
Zip Code
___ ___
State
$
.
Total Whole Miles Per Trip
(NO Decimals)
.
Total
Tolls/Parking/Bus
Minimum $3.00, Receipts Required
(Bus has no Minimum)
Name of Enrolled Provider and Facility/Group
Receipts Verified
Provider Type Code
(See list in shaded area)
Address of Provider (Where services were rendered)
Provider Type Codes:
(Select carefully, see
instructions)
[1] Hospital
[2] Physician/Mental Health Provider
[3] Dentist
__ __/__ __/__ __
[4] Therapies (Physical/Speech/Occupational)
[5] Dialysis
[6] Referral/Specialist***(see back)
[7] Pharmacy
[A] Medicaid Use Only
[B] Bus Transportation with Receipts
*** Provider/Pharmacy Signature and Date (must be signed on the date of service)
Trip Date (MM/DD/YY)
*CPT/CDT Code
I certify that NH Medicaid covered services were rendered for this recipient on the trip date
indicated.
Signature ____________________________________
*** If Pharmacy, do you provider free delivery to recipient’s residence? Yes
No
Today’s Date __________
*** Is the RX covered by Medicare Part D? Yes
No
*** This is to certify that the information above is true, accurate, and complete. I understand that payment of this claim may be from Federal and
State funds and that any false claim, statements, documents, or concealment of material fact may be prosecuted under applicable Federal and
State Laws.
Member Signature: ________________________________________________________
Date: __________________
Payee Signature:
Date: __________________
________________________________________________________
Please send a hard copy of the completed form to: 2500 Abbott Place, Attn: Mileage Reimbursement Team, St. Louis, MO
63143. Please keep a copy for your records. To check on the status of your reimbursement, please call 1-866-874-0222