Medicaid Transportation Sc Form – Fill Out and Use This PDF

13A(i) Web 07/12

INSTRUCTIONS FOR COMPLETING FORM 13A:

MEDICAID TRANSPORTATION REIMBURSEMENT FORM

PAYEE INFORMATION:

Key Name: Print the Key Name received upon enrollment. If you do not have a key name or have not been enrolled, contact the Medicaid Transportation Coordinator at 1-800-852-3345, ext.3770 (in-state only) or (603) 271-3770.

Resource #: Print the assigned Resource Number received upon enrollment. If you do not have a Resource Number or have not been enrolled, contact the Medicaid Transportation Coordinator at 1-800-852-3345, ext. 3770 (in-state only) or (603) 271-3770.

Payee Name: Print the first and last name, full mailing address, physical address (if different than the mailing)and telephone number of the person who will receive the payment.

Relationship to Recipient: Check the box that applies to your relationship to the recipient.

RECIPIENT INFORMATION:

First Name: Print up to the first three letters of the first name of the Medicaid recipient.

Last Name: Print up to the first three letters of the last name of the Medicaid recipient.

Medicaid ID #: Print the Medicaid recipient’s individual number from his/her Medicaid card.

TRIP INFORMATION: PLEASE COMPLETE ONE SIDE OR THE OTHER, NOT BOTH

If payee is Self or Parent/Household Member (Recipient		OR:			If payee is Volunteer
	Transporter)
From:	Print up to the first 8 letters of the Recipient’s home town		From: Print up to the first 8 letters of the Volunteer’s
	or city, and the zip code.				hometown or city, and the zip code.
To:	Print up to the first 8 letters of the Medical Provider’s		To:		Print up to the first 8 letters of the Recipient’s home town or
	town or city and state.				city.
			To: Print up to the first 8 letters of the Medical Provider’s town
					or city and state.

One Way/Round Trip: Check if the trip was made only one way, or if it was round trip (round trip means to the medical provider and return to the recipient’s home).

Total Miles per Trip: Enter the number of miles traveled on the trip date. For volunteers, total miles should be from your residence and return if it was round trip. (Leave blank if provider type code is B). This needs to be whole miles only. (For example: If you travel 25.2 miles, enter 25. If you travel 25.7 miles, enter 26.)

Tolls/Parking/Bus: If tolls and parking for this trip total $3.00 or more, enter the total amount. Enter full bus fare, if applicable. Receipts containing the trip date must be attached and must show the same trip date as stated on the claim form.

Address of Medicaid provider where services were rendered: Enter the street address including the city and state where services were

rendered.

Medical Provider Type Code: Enter the provider type code from the list in the shaded area below the code (1, 2, 3, etc.) Be very careful when selecting the code, as there are limits on each. Please note: specialists, regardless of where they are

seen, need to be coded w/a “6”. Please call if you have questions.

Trip Date: Enter the month, day and year the medical service was provided. This should be the date the transportation was provided.

CPT/CDT: You may be asked by the Transportation Coordinator to have the medical provider’s office enter the code corresponding to the services rendered to ensure validation of coverage.

Medical Provider/Pharmacy Signature: The Medicaid recipient (patient), or their authorized representative, is responsible for obtaining the medical provider’s signature on this claim form at the time of service. The medical provider or a

member of his/her staff must sign and date this form on the same day of the trip. If the provider is using a signature stamp, both the yellow and white copies must be stamped.

Recipient Signature and Date: The Medicaid recipient must sign and date the form. If the recipient is a minor, the parent or legal guardian must sign on his/her behalf.

Payee Signature and Date: The payee signs and dates the form after s/he has made sure the form is complete.

PROCESSING INFORMATION: Claims must be received by the Medicaid Transportation 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, send the white copy of this claim to: Medicaid Transportation, 129 Pleasant St, Thayer Bldg; Concord, NH 03301

Keep the yellow copy for your record so that you may compare the claim for services provided with the payments received. Please allow 6 to 8 weeks for payment of a claim. Claims that contain errors may need to be returned to you for correction.

SR 99-46 (3YC)

State of New Hampshire	13A Web
Department of Health and Human Services	07/12

****INSTRUCTIONS ON BACK OF FORM****

PAYEE /RESOURCE INFORMATION
Key Name: ___ ___ ___ ___ ___	Resource #: ___ ___ ___ ___ ___ ___ ___ ___

RECIPIENT INFORMATION (person receiving Medicaid services)

___ ___ ___

___ ___ ___

___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

Recipient First Name (1ST 3 only)

Recipient Last Name (1ST 3 only)

Recipient Medicaid ID Number

TRIP INFORMATION

Recipient Transporter Trip Information

Volunteer Transporter Trip Information

From:

From:

___ ___ ___ ___ ___ ___ ___ ___

___ ___ ___ ___ ___

___ ___ ___ ___ ___ ___ ___ ___

___ ___ ___ ___ ___

(Volunteer’s Home Town/City)

(Zip Code)

(Recipient’s Home Town/City)

(Zip Code)

To:

To:

OR

___ ___ ___ ___ ___ ___ ___ ___

(Recipient’s Home Town/City)

___ ___ ___ ___ ___ ___ ___ ___

___ ___

To:

(Medical Provider’s Town/City )

(State)

___ ___ ___ ___ ___ ___ ___ ___

___ ___

(Medical Provider’s Town/City)

(State)

1. One Way Trip

___ ___ ___

$___ ___.___ ___

$___ ___ ___.___ ___

2. Round Trip

Total Whole Miles Per Trip

Tolls/Parking/Bus

Receipts Verified

OMBP Use Only

(NO Decimals)

(Minimum $3.00, Receipts Required)

OMBP Use Only

(BUS HAS NO MINIMUM)

Name of Enrolled NH Medicaid Provider & Facility/Group they work for:

_____________________________________________________________

Medical Provider Type Code:

(See list below in shaded area)

_____________________________________________________________

Address of Medicaid provider where services were rendered

_____________________________________________________________

Medical Provider Type Codes:

[1] Hospital

[4] Therapies (Physical/Speech/Occupational)

[7] Pharmacy

(Select Carefully,

[2] Physician/Mental Health Provider [5] Dialysis

[A] Medicaid Use Only

see instructions)

[3] Dentist

[6] Referral/Specialist *** (See back of form)

[B] Bus Transportation with receipts

***Medical Provider/Pharmacy Signature & Date (must be signed on date of service)

Trip Date (MM/DD/YY)

I certify that NH Medicaid covered services were rendered for this recipient on the trip date

indicated.

___ ___ /___ ___ /___ ___

_______

_______

___

_______

* CPT/CDT Code

Signature

Today’s

Date

***If Pharmacy, do you provide free delivery to recipient’s residence?

Yes

No ***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 claims, statements, documents or the concealment of material fact may be prosecuted under applicable Federal and State Laws.

Recipient Signature:					Date:
Payee Signature:					Date:
Send original to Medicaid Transportation			Please keep a copy for your records				SR 99-46
							(3YC)