Modivcare Mileage Reimbursement Form Instructions
This file provides essential details and instructions for filling out the Modivcare Mileage Reimbursement form. Users can learn how to complete the form correctly for timely reimbursement. Ensure that all necessary signatures and trip details are included to avoid delays.
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How do I fill this out?
To fill out the Modivcare Mileage Reimbursement form, first gather all necessary information regarding your trips to medical appointments. It’s crucial to have your doctor or counselor sign the form after each visit. Make sure to keep the trip numbers handy as they are required for the reimbursement process.
How to fill out the Modivcare Mileage Reimbursement Form Instructions?
1
Call to schedule your trip and obtain a trip/job number.
2
Fill out the entire form, excluding the Physician/Clinician Signature area.
3
Bring the form to your medical appointment for a signature.
4
You may list up to seven trips on a single form.
5
Mail the completed form to the Modivcare Claims Department.
Who needs the Modivcare Mileage Reimbursement Form Instructions?
1
MO HealthNet participants needing to receive mileage reimbursement.
2
Drivers transporting Medicaid members to medical appointments.
3
Caregivers managing transportation for their relatives to medical visits.
4
Healthcare providers requesting reimbursement referrals for their patients.
5
Social workers aiding clients in completing mileage documentation.
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1
Open the Modivcare Mileage Reimbursement form in PrintFriendly.
2
Use the editing tools to fill in all necessary fields.
3
Add signatures where required by clicking on the sign feature.
4
Review all entries for accuracy.
5
Download or print the completed form.
What are the instructions for submitting this form?
To submit the completed Modivcare Mileage Reimbursement form, mail it to Modivcare Claims Department at 798 Park Avenue NW, Norton, VA 24273. Ensure that all sections are filled, including necessary signatures before sending. For assistance or inquiries, contact Modivcare Claims at 800-930-9060.
What are the important dates for this form in 2024 and 2025?
For 2024, ensure you submit your mileage forms on time to meet deadlines and guarantee reimbursement. If you're planning trips in advance, it's important to schedule them within the required time frame. Monitor any updates for 2025 once available to stay compliant.
What is the purpose of this form?
The purpose of the Modivcare Mileage Reimbursement form is to facilitate the process for MO HealthNet participants to claim reimbursement for travel expenses incurred while attending medical appointments. This document ensures that individuals are compensated fairly for their transportation costs associated with necessary healthcare services. It serves as a crucial link between service users and healthcare providers, streamlining the reimbursement workflow.
Tell me about this form and its components and fields line-by-line.
- 1. Driver Name: The name of the person driving the Medicaid member.
- 2. Driver Mailing Address: The address where the driver can receive mail.
- 3. Member Name: The name of the Medicaid member if different from the driver.
- 4. Trip Date: The date the medical appointment occurred.
- 5. Trip/Job #: The unique number assigned to the trip by Modivcare.
- 6. Medical Provider Name & Phone #: Contact details of the healthcare provider.
- 7. Physician/Clinician Signature: Signature from the attending physician as proof of the visit.
- 8. Total Miles: The total distance traveled for the appointment.
What happens if I fail to submit this form?
Failing to submit the Modivcare Mileage Reimbursement form can result in non-payment for your travel expenses. Incomplete forms or forms missing required signatures will not be processed, leading to delays in receiving reimbursement.
- Incomplete Submission: Forms must be fully completed; missing information will cause rejections.
- Lack of Necessary Signatures: All required signatures must be present, or the form will be invalid.
- Deadline Issues: Submitting after the deadline will prevent processing for reimbursement.
How do I know when to use this form?
- 1. Medical Appointments: Use this form for any trips attended for medical care.
- 2. Therapy Sessions: Reimbursement can be claimed for travel to therapy sessions.
- 3. Doctor Visits: All trips to see your doctor should be documented using this form.
Frequently Asked Question
How can I download the Modivcare form?
You can easily download the Modivcare form after editing it in PrintFriendly. Simply click the download button once you’ve completed your edits.
What if I forget my trip number?
If you forget your trip number, please contact Modivcare’s Reservation Line for assistance. They can help retrieve your trip information.
Can I edit the form after saving it?
Yes, you can always go back to PrintFriendly to make further edits if needed before the final submission.
Do I need to keep a copy of the form?
It is advisable to keep a copy of the submitted form for your records, ensuring you have proof of your mileage claim.
What happens if my form is incomplete?
An incomplete form will result in a denial of your reimbursement request, so be sure to fill in all required fields.
How long does it take to get reimbursed?
Reimbursement payments will be mailed within 30 days after the Modivcare Claims Department receives your completed form.
Can I submit more than one trip on a single form?
Yes, you can put up to seven trips on one reimbursement form for convenience.
Is there a deadline for submitting the form?
The form should be submitted no later than 5 pm on the day of the appointment.
Who should sign the form?
Your doctor or counselor must sign the form as proof of your appointment for reimbursement to be processed.
Where do I send the completed form?
The completed form must be sent to the Modivcare Claims Department at their designated address.
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