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How do I fill this out?
Filling out the mileage reimbursement form is straightforward. Begin by gathering necessary appointment and driver information. Ensure all required fields are completed for a smooth process.
How to fill out the Maine Mileage Reimbursement Guidelines?
1
Call the reservation line 48 hours before your appointment.
2
Fill out your trip log with all required information.
3
Have your doctor sign the completed voucher at the appointment.
4
Mail or fax the completed reimbursement log and receipts.
5
Submit the log no later than 60 days after the appointment.
Who needs the Maine Mileage Reimbursement Guidelines?
1
Medicaid beneficiaries requiring transport to appointments.
2
Caregivers responsible for submitting travel claims.
3
Healthcare providers validating patient transportation.
4
Individuals assisting others in accessing medical services.
5
Anyone needing reimbursement for approved mileage costs.
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What are the instructions for submitting this form?
To submit this form, either mail it to Modivcare Claims Department-Maine, or fax it to 1-866-528-0462. Ensure that all required documentation is attached, including receipts for tolls. For questions regarding your claim, please call 877-659-1308.
What are the important dates for this form in 2024 and 2025?
Important dates include the reimbursement rate change effective on July 1, 2018, and submission deadlines. Always ensure forms are submitted within 60 days of the appointment for reimbursement eligibility.
What is the purpose of this form?
The purpose of this reimbursement form is to provide beneficiaries with a structured process for claiming mileage expenses incurred during medical appointments. It ensures that all necessary information is collected to facilitate timely and accurate reimbursements. The form also helps track travel expenses for compliance with Medicaid regulations.
Tell me about this form and its components and fields line-by-line.
- 1. Appointment Information: Details of the medical appointment including date and time.
- 2. Driver Information: Name and mailing address of the driver providing transportation.
- 3. Trip Log: Records of the trip including start and stop locations.
- 4. Signature: Section for the doctor/clinician's signature confirming attendance.
What happens if I fail to submit this form?
Failure to submit this form correctly can lead to denial of reimbursement. It's essential to ensure that all required details are filled out accurately to avoid delays. Incomplete submissions will result in requests for additional information, extending the reimbursement process.
- Inaccurate Information: Missing or incorrect details may cause denial of claims.
- Late Submission: Forms submitted after the 60-day period will not be processed.
- Insufficient Documentation: Failure to provide complete documentation will delay payments.
How do I know when to use this form?
- 1. Routine Medical Visits: For trips to regular check-ups and specialist consultations.
- 2. Emergency Appointments: To claim mileage for unscheduled emergency visits.
- 3. Therapy Sessions: When attending physical therapy or related sessions.
- 4. Diagnostic Tests: For travel to appointments for necessary diagnostic procedures.
- 5. Follow-Up Care: To cover mileage for required follow-up medical consultations.
Frequently Asked Questions
How do I submit my mileage reimbursement?
You can submit your form by mailing it to the Modivcare Claims Department or faxing it to the provided number.
What information do I need to fill out the form?
You will need appointment details, driver information, and your trip log.
Can I submit for multiple trips?
Yes, but please submit each member's trips on separate logs for accurate processing.
What if I miss the submission deadline?
Late submissions may result in payment denial, so ensure prompt submission.
Where do I send my completed form?
Mail it to the Modivcare Claims Department-Maine at the listed address.
What is the new mileage reimbursement rate?
The new mileage reimbursement rate is $0.21 per loaded mile.
How long does it take to receive my reimbursement?
Checks are typically mailed out within 30 days after receipt.
What should I do if my trip log is incorrect?
Review and edit your log for accuracy before submission.
Can I use the PDF editor to fill out other forms?
Yes, PrintFriendly allows you to edit various PDF forms with ease.
Is there a customer service number for questions?
For assistance, you can contact the mileage reimbursement claim line at 877-659-1308.
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