Transportation Provider Downloads

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 TitleDescription 
Billing Invoice FormThe summary form which the transportation provider must submit with completed Trip Logs that includes the amount billed for all trips submitted.Download
Virginia NEMT Trip LogThe form which must be completed, daily, which indicates the specifics of the assigned trip and has been signed by the member or his representative when the trip has been completed.Download
Provider Payment Schedule—2014A document which shows the schedule of payments which will be made during the year 2014.Download
Virginia Medicaid/FAMIS Appeal FormA form the transportation provider uses to explain reasons for appealing LogistiCare’s decision.Download
Resubmit Trip LogA form which the transportation provider can use to resubmit corrected billing which was originally denied.Download
Volunteer Driver FlyerInforms who volunteer drivers are and lists the requirement of becoming a volunteer driver.Download
Region 1 - Cancellation ReportA form which the transportation provider must submit daily to disclose trips which were not performed (specific to Region 1).Download
Region 2 - Cancellation ReportA form which the transportation provider must submit daily to disclose trips which were not performed (specific to Region 2).Download
Region 3 - Cancellation ReportA form which the transportation provider must submit daily to disclose trips which were not performed (specific to Region 3).Download
Region 4 - Cancellation ReportA form which the transportation provider must submit daily to disclose trips which were not performed (specific to Region 4).Download
Region 5/6 - Cancellation ReportA form which the transportation provider must submit daily to disclose trips which were not performed (specific to Regions 5 and 6).Download
Region 7 - Cancellation ReportA form which the transportation provider must submit daily to disclose trips which were not performed (specific to Region 7).Download
Region 1 - Reroute FormA document which the transportation provider uses to return trips to LogistiCare for reassignment (specific to Region 1).Download
Region 2 - Reroute FormA document which the transportation provider uses to return trips to LogistiCare for reassignment (specific to Region 2).Download
Region 3 - Reroute FormA document which the transportation provider uses to return trips to LogistiCare for reassignment (specific to Region 3).Download
Region 4 - Reroute FormA document which the transportation provider uses to return trips to LogistiCare for reassignment (specific to Region 4).Download
Region 5/6 - Reroute FormA document which the transportation provider uses to return trips to LogistiCare for reassignment (specific to Regions 5 and 6).Download
Region 7 - Reroute FormA document which the transportation provider uses to return trips to LogistiCare for reassignment (specific to Region 7).Download
LogistiCare 5 Day Notice Requirement Flyer for Routine Appointments.Informs members a 5 day notice is required to schedule non-emergency transportation for Routine Appointments.Download
Tips for Arranging Medicaid Non-Emergency TransportationProvides Tips for members on how to arrange FFS Medicaid Non-Emergency Transportation.Download
EFT Form (Electronic Funds Transfer)A document which the transportation provider may submit to the Claims Center to establish direct deposit of checks.Download
Retroactive FormA document which the transportation provider can use to file for payment for a preauthorized trip provided prior to Medicaid being approved and backdated.Download

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