Form 13a9i) - Medicaid Transportation Reimbursement Form

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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.
Medicaid Provider Name & Facility/Group they work for:
Print the name of the medical service provider, in last name, first name order.
SMITH, JOHN; ABC PEDIATRICS
Example:
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)

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