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How do I fill this out?
Filling out the mileage reimbursement form is straightforward. Begin by inputting the trip number and date received from ModivCare. Be sure to have your physician or clinician sign the designated area to verify your appointment.
How to fill out the ModivCare Mileage Reimbursement Instructions?
1
Receive a trip number when scheduling your appointment.
2
Fill out the entire reimbursement form excluding the physician's signature.
3
Obtain a signature from your healthcare provider on the form.
4
Submit the form via mail, email, or fax.
5
Ensure submission occurs within the required timeline for reimbursement.
Who needs the ModivCare Mileage Reimbursement Instructions?
1
Individuals who drive themselves to medical appointments to claim reimbursement.
2
Caregivers who transport patients and need to reclaim travel costs.
3
Medi-Cal beneficiaries who have transportation expenses after appointments.
4
Healthcare providers who assist patients with filling out the form.
5
Non-profit organizations helping clients who need medical transportation.
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1
Open the PDF in PrintFriendly.
2
Select the editing tool and fill in your trip information.
3
Make any necessary adjustments or edits to the document.
4
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5
Download or share your edited PDF once finalized.
What are the instructions for submitting this form?
To submit the mileage reimbursement form, ensure that all details are correctly filled out. You can mail the completed form to 798 Park Avenue NW, Norton, VA 24273, email it to Virginia.billingoperations@modivcare.com, or fax it to 866-528-0462. Ensure that your submission is made on or before your medical appointment date and within 30 days to ensure timely processing.
What are the important dates for this form in 2024 and 2025?
For 2024 and 2025, the reimbursement forms must be submitted by the appointment date and received within 30 days for timely processing. Ensure you keep track of your medical appointment dates and adhere to these timelines to avoid claim denials.
What is the purpose of this form?
The mileage reimbursement form is designed to assist Medi-Cal beneficiaries in reclaiming travel costs incurred while attending medical appointments. It aids users in documenting and verifying their commuting expenses for eligible trips. This system ensures that necessary funds are returned to beneficiaries, easing the financial burden of medical travel.
Tell me about this form and its components and fields line-by-line.
- 1. Patient Name: The name of the individual receiving medical services.
- 2. Trip Number: A unique identifier assigned to each scheduled trip.
- 3. Date of Trip: The date when the transportation occurred.
- 4. Physician/Clinician Signature: Space for authentication by the attending healthcare professional.
- 5. Mileage: Total distance traveled in connection with the medical appointment.
- 6. Address of Appointment: The location where the medical services were provided.
What happens if I fail to submit this form?
Failure to submit the mileage reimbursement form may result in denial of reimbursement claims. It is critical to adhere to submission deadlines to ensure processing is completed in time. Ensure that all required information is accurately provided to avoid complications.
- Claim Denial: Submitting forms after deadlines can lead to the rejection of your reimbursement request.
- Unverified Trips: Missing information may result in claims not being honored, requiring you to resubmit.
- Financial Impact: Failure to secure reimbursement can lead to unexpected personal expenses related to travel.
How do I know when to use this form?
- 1. Medical Appointments: Use this form if you have attended a healthcare-related visit.
- 2. Claiming Mileage: This form is specifically designed for documenting travel expenses for reimbursement.
- 3. Multiple Trips: Utilize this form to report costs for several visits within the specified limits.
Frequently Asked Questions
How do I fill out the mileage reimbursement form?
Begin by writing down your trip number, fill in the required fields, and ensure a physician's signature is obtained.
What is the deadline for submitting this form?
The form must be submitted on or before the medical appointment date and received within 30 days.
Can I submit multiple trips on one form?
Yes, you can list up to seven trips on a single reimbursement form.
How will I receive my reimbursement?
Payment will be mailed within thirty business days after the completed form is received.
What if I forget my trip number?
Forgetting your trip number may result in denial of your reimbursement; contact ModivCare for assistance.
Is there a limit on the number of drivers per form?
Yes, only one driver can be listed on each form. Submit separate forms for additional drivers.
What should I do if my reimbursement is denied?
Contact the ModivCare Claims Department for clarification and possible dispute resolution.
Can I edit this PDF after filling it out?
Yes, you can edit the PDF on PrintFriendly before finalizing it for submission.
What should I do if my physician refuses to sign?
You should seek another healthcare provider's signature as proof of your appointment.
How can I contact ModivCare for assistance?
You can reach the ModivCare Claims Department at 1-800-930-9060 for help with your reimbursement.
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