Reimbursement Trip Log at a glance
What it is: The Reimbursement Trip Log is the form you submit to MTM to be reimbursed for your trip requests.
Who signs: Any healthcare professional at the facility can sign the Trip Log. This includes nurses, therapists, physician assistants, or nurse practitioners. It doesn't have to be the doctor. Sign under Signature of Member, Parent/Legal Guardian, or Representative to verify that the information on this trip log is true. The Transporter/Driver signs the Attestation of Transportation Provider Qualifications.
What to bring and attach to Reimbursement Trip Log
You must call MTM on or before the day of your medical appointment. You will receive a trip number during this call. You will need to write the number down on this Trip Log.
If you don't have a Trip Log, ask your healthcare provider for a note on their facility letterhead. The note should state that you were seen and the date of the appointment. Once you have a new trip log, attach the note from your healthcare provider in place of a signature.
A filled-in Reimbursement Trip Log example: a member logs one round trip
How to fill out Reimbursement Trip Log, box by box
Member Info
Under Member Info, enter First Name, Last Name, Medicaid #, Address, Phone, City, State and Zip.
Payment Info
Under Payment Info, enter whom to make the MTM Re-Loadable Debit Card payable to, the Relationship to Member (Self or Other), Date of Birth, Address, Phone, City, State and Zip.
Trip #1 to Trip #7
Enter the Medicaid/Medicare ID# at the top of the continued Reimbursement Trip Log.
On each Trip line, enter the Trip Number (Call MTM for this before your trip), the Appointment Date and the Appointment Time, and under Type mark Round Trip or One-Way.
A one-way trip is from your home to the appointment. A round trip is from your home to the appointment and then back home.
Under Address where you were picked up, mark Home or Other and enter the address.
Enter the Healthcare Provider Name, Healthcare Provider Phone and Healthcare Provider Address.
The Healthcare Provider certifies that this patient was seen for a Medicaid covered health service, with a Signature & Title of Healthcare Provider.
Sign under Signature of Member, Parent/Legal Guardian, or Representative to verify that the information on this trip log is true.
Attestation of Transportation Provider Qualifications
Attestation of Transportation Provider Qualifications, Consolidated Appropriations Act of 2021: the Transporter/Driver signs this attestation. By signing this form, you (the Transporter/Driver) attest that:
You are not banned from joining in any federal health care program (listed on the MDHHS sanctioned provider list or the U.S. Department of Health and Human Services exclusion list).
You have not been found guilty of a federal or state law after August 21, 1996, for a felony related to the unlawful making, distributing, prescribing, dispensing of a controlled substance.
You will tell Meridian of any felony related to a controlled substance and traffic violation that you are guilty of.
You have a valid driver's license.
In the past two years, you have not been found guilty of: More than two moving violations, Operating While Intoxicated (OWI), Driving Under the Influence (DUI).
The Transporter/Driver (Name) enters a Signature and a Date.
More rules for Reimbursement Trip Log
Incomplete forms cannot be processed. It is your responsibility to complete this form correctly. Keep a copy of your Trip Log for your records.
If you need a new copy of this form, you may call and request one be mailed to you, or you may download this form at www.memberportal.net.
Questions about the Reimbursement Process? Please call: 1-888-513-0703.
If your situation is different
A trip has more stops
For trips with more stops, such as an extra trip from the first appointment to a second appointment before going back home, please enter each trip leg on a separate line: 1st leg-home to first doctor, 2nd leg-first doctor to second doctor, 3rd leg-second doctor to home.
Mail, fax, or email completed logs
Mail, fax, or email completed logs to: MTM, Attention: Trip Logs 16 Hawk Ridge Dr. Lake St. Louis, MO 63367 Fax: 1-888-513-1610 Email: payme@mtm-inc.net
Submit Trip Logs no more than 60 days past the date of the first appointment.
Sources
[1] Reimbursement Trip Log (Revised September 2016), MTM (the Official source link on this page).
