Edit, Download, and Sign the ModivCare Mileage Reimbursement Trip Log Form
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How do I fill this out?
To fill out this form, provide all required information about the driver, the Medicaid member, and the trips taken. Ensure each trip date has a physician or clinician signature. Submit the completed form to the specified ModivCare Claims Department.
How to fill out the ModivCare Mileage Reimbursement Trip Log Form?
1
Enter the driver's name, mailing address, and phone number.
2
Fill in the member's name, Medicaid ID number, and relationship to the driver.
3
Provide trip dates, job confirmation numbers, and medical provider details.
4
Obtain physician or clinician signatures for each date of service.
5
Send the completed form to ModivCare Claims Department.
Who needs the ModivCare Mileage Reimbursement Trip Log Form?
1
Drivers who transport Medicaid members for medical appointments need this form to get reimbursed for mileage.
2
Medicaid members who use transportation services may need this form for reimbursement claims.
3
Medical providers might need this form to certify the trips taken by Medicaid members.
4
Transportation coordinators can use this form to manage and document trips efficiently.
5
Healthcare organizations may require this form to ensure proper documentation and reimbursement for transportation services.
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What are the instructions for submitting this form?
Complete all required fields on the form, ensuring accuracy and obtaining the necessary signatures. Send the completed form to ModivCare Claims Department at 798 Park Avenue NW, Norton, VA 24273. Alternatively, submit online if available, or fax to the provided number.
What are the important dates for this form in 2024 and 2025?
Important submission dates for this form include the end of each quarter in 2024 and 2025, ensuring timely reimbursement processing.
What is the purpose of this form?
The purpose of this form is to facilitate mileage reimbursement for drivers who transport Medicaid members for medical appointments. By providing detailed trip information, this form ensures transparency and accountability in mileage claims. The required physician or clinician signature validates the trips, making sure only legitimate trips are reimbursed.
Tell me about this form and its components and fields line-by-line.
- 1. Driver name: Full name of the driver.
- 2. Driver mailing address: Mailing address of the driver, including City/State/ZIP.
- 3. Driver phone number: Contact phone number of the driver.
- 4. Member name: Full name of the Medicaid member.
- 5. Relationship to member: Driver's relationship to the Medicaid member.
- 6. Member Medicaid ID number: Unique Medicaid identification number of the member.
- 7. Trip date: Date(s) the trip occurred.
- 8. Trip/job confirmation number: Confirmation number for the respective trip or job.
- 9. Medical provider name and phone number: Name and contact details of the medical provider.
- 10. Physician/clinician signature: Signature of the physician or clinician for each date of service.
- 11. Total miles: Total miles traveled for all trips.
- 12. Total mileage to be paid: Calculated total mileage for payment purposes.
- 13. Total amount for this invoice: Total remuneration amount for the completed mileage.
What happens if I fail to submit this form?
Failure to submit this form may result in delays or denial of mileage reimbursement claims.
- Delayed reimbursement: Claims processing may be delayed, affecting timely payment.
- Denial of claims: Incomplete or unsubmitted forms may lead to denied reimbursement claims.
How do I know when to use this form?
- 1. Medical appointments: Use for trips taken to medical appointments.
- 2. Routine check-ups: Use for routine medical check-ups.
- 3. Emergency visits: Use for emergency medical visits.
- 4. Specialist consultations: Use for trips to see a specialist.
- 5. Therapy sessions: Use for transportation to therapy and rehabilitation sessions.
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