Submit the completed forms and documents online via the IHCP portal or by mail to the IHCP Provider Enrollment Unit at P.O. Box 7263, Indianapolis, IN 46207-7263. Ensure that you include all required documents like the Medicaid Family Member or Associate Transportation Services Form and any identification materials for the driver. For inquiries, you can call 844-772-6632 or email gas@welltransnemt.com for clarification.

For the years 2024 and 2025, keep an eye out for any updates regarding gas reimbursement policy changes from the Indiana Health Coverage Programs. Regularly check for application deadlines and recertification requirements to ensure compliance and continued reimbursement eligibility.

The purpose of this form is to facilitate the gas reimbursement process for Medicaid recipients who require transportation to their medical appointments. By completing this form, drivers can receive compensation for miles traveled while assisting Medicaid members. This ensures that those in need can access essential healthcare services without the added financial strain of transportation costs.

• 1. Driver's Name: The full name of the individual driving the Medicaid member.
• 2. Driver's Relationship: The relationship of the driver to the Medicaid member, such as friend or relative.
• 3. Mileage: The total miles driven for the trip.
• 4. Trip Reference Number: A unique number assigned to the trip by WellTrans during scheduling.
• 5. Member's Medicaid ID: The Medicaid identification number for the member receiving transport.

Failure to submit this form may result in the inability to receive reimbursement for gas expenses incurred while transporting a Medicaid member. This can lead to financial strain for drivers who are relying on compensation for their expenses.

• Ineligible Reimbursement: Without the form, drivers will not be able to receive gas reimbursement.
• Delayed Payments: Submitting the form late may result in delays beyond the reimbursement timeline.
• Inaccurate Information: Incomplete forms can lead to processing errors and rejected claims.
• Loss of Approval: Drivers may lose their approval status if forms are not submitted on time.
• Financial Burden: Without reimbursement, drivers may incur significant expenses for medical transport.

• 1. Transportation to Medical Appointments: For rides taken to and from Medicaid providers.
• 2. Reimbursing Friends or Family: If you drive someone else to their appointments.
• 3. Maintaining Approval Status: To renew your driver's approval with IHCP.
• 4. Documenting Trips: To keep records of transportation for financial tracking.
• 5. Filing for Recertification: When changes occur that require submission of updated information.