Intelliride 25 Mile Form. View the IntelliRide Medical Recommendation Form in our colle

View the IntelliRide Medical Recommendation Form in our collection of PDFs. o The driver will wait up to 15 minutes after the scheduled pick-up time before leaving. com Mail: 2222 Cuming Street Omaha, NE 68102 Verification form for transportation services more than 25 miles The member’s medical provider must complete this form to verify the medical necessity of trips that exceed 25 miles, one way. In Colorado, we need a strong network of independent drivers and transportation providers as well as volunteers, local residents Dear Medical Professional: IntelliRide has received a request for transportation for one of your patients. Call IntelliRide at 1-866-790-8858 to schedule your trip. Please fill out this Level of Service Medical Recommendation Form completely and provide any supporting information as needed. All travel beyond 25 miles, will require the Beyond 25 mile authorization form which can be found below. gov/nemtlist. . It’s EASY! Have a friend, neighbor or relative drive you to your appointment. Created Date. Verification form for transportation services more than 25 miles The member’s medical provider must complete this form to verify the medical necessity of trip requests that exceed 25 miles, one way. intelliride@transdev. IntelliRide manages non-emergency medical and non-medical transportation for Health First Colorado members (Medicaid) in the state of Colorado. Or go to transdevhealthsolutions. Use a separate form for each date of service. Yes, they are already up and available. They accept trip reservations and arrange member rides for covered services with qualified transportation providers. Effective May 1, 2024, the member’s referring or treating provider must complete the Verification Form for Transportation Services More Than 25 Miles, located on the Provider Forms web page under the Claim Forms and Attachments drop-down, to verify the medical necessity of trip requests that exceed 25 miles, one way. Please submit one form per member. pdf . Please send completed form to: Fax (720) 302. To schedule new trips, or confirm existing trips for after 9/1/2019, call IntelliRide at (303) 398-2155 or (855) 489-4999. MedRide is a Non Emergency Medical Transportation (NEMT) company based out of Colorado. Dear Medical Professional: This form will be used to determine the members most appropriate mode of transportation based on his or her functional abilities and limitations. The member's medical provider must complete this form to verify the medical necessity of trip requests that exceed 25 miles, one way. You can find local ride providers at hcpf. We offer medicaid rides, private pay transportation, and facility/provider transportation for both ambulatory and wheelchair patients. 5-1-118) and rules of the state department. Send us your finished Mileage Reimbursement Verification Form or itemized copies of hotel and meal receipts within 10 business days of your appointment Mileage Reimbursement Verification Form (Single Trip) Fax: (402) 934‐8622 claims. What should I expect on the day of my appointment? • Be ready at least 10 minutes before the driver is scheduled to arrive. Dohmen, Tamara . NEMT transportation is rides to and from covered medical appointments or services. When scheduling your trip, IntelliRide will give you the below details. 8622 or mail it to 2222 Cuming Street, Omaha, NE 68102. IntelliRide by transdev . 0106 | Email: us. com/colorado/. colorado. Round trip distance in miles Trip number Write these two numbers on your Mileage Reimbursement Form. We will help you with travel What We Do IntelliRide will work directly with Health First Colorado to confirm your eligibility for transportation services and to ensure your request is for a Medicaid covered service. Level Of Service Medical Provider Agreement & Signature Once your trip is completed, you can email the form to claims. A client’s provider or care coordinator may submit the Medical Certificate form (MCTS) to Intelliride to request privately contracted vehicles, or mileage reimbursement, as they of Transportation Services Transdev manages non-emergency medical and non-medical transportation for Health First Colorado members in the state of Colorado. com Mail: 2222 Cuming Street Omaha, NE 68102 We would like to show you a description here but the site won’t allow us. Mileage Reimbursement Verification Form (Subscription) Fax: (402) 934‐8622 claims. What We Do IntelliRide will work directly with Health First Colorado to confirm your eligibility for transportation services and to ensure your request is for a Medicaid covered service. Please complete this form and return it to IntelliRide for reimbursement of your mileage within 10 business days of your medical appointment. Member’s medical provider must complete the Verification Form for Transportation Services More Than 25 Miles to verify the medical necessity of trip requests that exceed 25 miles, one way. We focus on providing safe and timely transportation to give Medicaid members more flexibility, freedom and control over their personal health. Your trip must be within 25 miles of the pick-up location (additional forms are required if needing farther transportation). com Mail: 2222 Cuming Street Omaha, NE 68102 As of September 1, 2019, IntelliRide will be the new broker for Health First Colorado’s NEMT benefit. Schedule a ride to your medical appointment and get a refund. 014, Non-Emergent Medical Transportation. IntelliRide will answer your calls for general information and to schedule, change or cancel trips; manage complaints; and, help locate drivers that are running behind schedule. Members can schedule trips through IntelliRide or be reimbursed at 44 cents per mile if driven by a friend or family member. This trip must meet the requirements in 10CCR 2505-10 Section 8. Mail form to: 2222 Cuming Street, Omaha NE, 68102 Use this form to be reimbursed for eligible out-of-pocket travel expenses. Medical Certificate of Transportation Services Beyond 25 Miles To be valid, the Attending Physician, Physician’s Assistant, Nurse Practitioner, Therapist or other licensed healthcare professionals must fully complete and sign this certification form. Transport services are within the definition of • As the broker, IntelliRide handles administrative functions such as mileage reimbursement; they are not a transportation provider, but they maintain a network of subcontracted providers and drivers. Title. Health First Colorado Verification Form for transportation over 25 miles The member’s medical provider must complete this form to verify the medical necessity of trip requests that exceed 25 miles, one way. 489. To file a request: 1. com This form is valid for 90 days per member for regular trips to treatment locations. • Any additional passengers (a required escort), service animals, or medical equipment/devices How do I schedule a NEMT trip? If you live in the following counties, contact IntelliRide at 1-855-489-4999: • Adams • Broomfield • Jefferson • Arapahoe • Denver • Larimer • Boulder • Douglas • Weld Health First Colorado (Colorado’s Medicaid program) has a Non-Emergent Medical Transportation benefit that provides members with rides to medical appointments through IntelliRide. If you need a ride and live in any other Colorado county: Contact a local ride provider. 1/5/2024 10:14:20 AM . 934. Sign, print, and download this PDF at PrintFriendly. This form is valid for the identified Member for 90 days from the date of the initial visit to the treating provider. Verification form for transportation services more than 25 miles The members medical provider must complete this form to verify the medical necessity of trips that exceed 25 miles, one way. 25. MCTS-Beyond-25-miles. I think the only one that is working is the MCTS form for over 25 miles. coclinicalcoordinator@transdev. Health First Colorado (Colorado's Medicaid program) provides Non-Emergent Medical Transportation (NEMT) and mileage reimbursement for members who lack transportation to medical appointments. Mail form to: 98-1238 Kaahumanu Street, Suite #400, Pearl City, HI 96782 Use this form to be reimbursed for eligible out-of-pocket travel expenses. com Mail: 2222 Cuming Street Omaha, NE 68102 Call IntelliRide at 808-973-0712, Option 2 to schedule your trip. Please Transdev converted all forms from PDF to a completely digital process. View the IntelliRide Level of Service Medical Recommendation Form in our collection of PDFs. Example: If you went to the doctor and picked up a prescription on the same day. com, fax it to 402. Save or instantly send your ready documents. Health First Colorado members are required to travel to the closest medical facility that is able to provide the necessary treatment or services. Complete the information above. 4999 and choose Option 5 for ‘Where’s my ride?” Is IntelliRide able to assist with urgent trip requests and hospital discharges? Non-Emergent Medical Transportation Request Form Complete this form to request Non-Emergent Medical Transportation (NEMT) for Health First Colorado members who need out-of-state transportation. What happens if my ride does not show up? If your driver has not arrived at the scheduled pick up time, please call IntelliRide at 855. Mileage Reimbursement Verification Form (Single Trip) Fax: (402) 934‐8622 claims. As the state contracted broker for Health First Colorado, Transdev manages NEMT services for the entire state of Colorado. R. Easily fill out PDF blank, edit, and sign them. • Are the other links from the website for the forms, etc. going to be linked. Once your trip is completed, you can email the form to claims. The driver will get 50 cents for each mile they drive you. intelliride@Transdev. lntelliRide will confirm the member does not have an established relationship with a closer medical provider and that there are no closer providers with the capacity to accept new patients. Medical Certification for Transportation Services Beyond 25 Miles The member's medical provider must complete this form to verify the medical necessity of trip requests that exceed 25 miles, one way. Sharing of Protected Health Information (PHI) Data by Counties with IntelliRide County departments of human/social services act as the agent of the Department to administer the Medical Assistance Program and related activities in the respective counties in accordance with state statute (C. Complete Intelliride Standing Order Request Form 2020-2026 online with US Legal Forms. • When will the forms be available on the website? Specifically, the enrollment form for new Medicaid clients. S. We will help you with travel A client’s provider or care coordinator may submit the Medical Certificate of Transportation Services form (MCTS) to Intelliride to request privately contracted vehicles, or mileage reimbursement, as they feel it is medically necessary. Here is how to use the new forms: Access links to the new electronic forms at the bottom of this page in the “Medical Documentation” section – the same place you have accessed PDF forms in the past. Author. This form will be used to determine the patient’s most appropriate mode of transportation based on his or her functional abilities and limitations. Call Transdev/IntelliRide at 855-489-4999 (toll free) (State Relay 711).

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