Non-Emergency Medical Transportation Individual Transportation Participant (ITP) Program Service Delivery Area 1 In this packet you will find: A list of Items We Need to Sign-up a Driver for the program pg. 2 Driver History Form pg. 3 Driver Agreement Form pg. 4 Facts About the Driver Form pg. 5 A sheet explaining How to File a Claim pg. 6 ITP Program Driver Packet Page 1
Items We Need to Sign-up a Driver Use this checklist to make sure you send us all the items we need to sign you up as an approved driver. For help filling out these forms, call the LogistiCare Compliance Department at 877-564-9838 Monday to Friday from 8 a.m. until 5 p.m. You must send us each of the items listed on the checklist. The completed Facts About the Driver page you fill out. (Make sure you checked Yes or No for each statement about whether you are related to the person you will be driving.) The completed Driver History page you fill out. The completed Driver Agreement page you fill out. A copy of your current and valid auto insurance issued in the United States with coverage limits. (Your name must be listed on the card.) Must have minimum liability coverage required by the State of Texas Operating vehicles must be listed on the policy A copy of your current and valid driver s license. A copy of your Social Security card. Proof of current vehicle tag registration. Proof of current State of Texas annual safety inspection. Important: The name listed on your vehicle insurance card, driver s license, and Social Security card must be the same. If you have questions or if you need to make corrections, call LogistiCare s Compliance Department toll-free at 877-564-9838 Monday to Friday from 8 a.m. until 5 p.m. Send completed forms and copies of your driver s license, auto insurance, and Social Security card to: LogistiCare Solutions Compliance Department 12234 N. Interstate 35, Building B Austin, Texas 78753 ITP Program Driver Packet Page 2
Driver History A person who drives someone to a health-care visit and wants to be paid back for mileage must be approved by LogistiCare and enrolled as a driver. The driver must fill out and send in this Driver History page along with the other items listed on the Items we Need to Sign-up a Driver page (Page 2 of this packet). People with Medicaid coverage and those in the Children with Special Health Care Needs program also can be drivers and get paid back for mileage when they drive themselves to their own health-care visits. If you are driving yourself or a family member, fill out Section 1 only. If you are driving someone other than yourself or a family member, fill out Section 1 and Section 2. Be sure to answer all questions. Write NA for any question that does not apply to you. By signing the Driver Agreement on the following page, the driver is saying that all information given in the pages of this packet is true and complete. Section 1 Driver s Last name, first name, middle initial: Telephone number (if we need to contact you): Driver s Signature (if you re driving yourself or family member) Section 2 Sanction is defined as recoupment, payment hold, imposition of penalties or damages, contract cancellations, exclusion, debarment, suspension, revocation, or any other synonymous action. Have you ever been sanctioned (as defined above) in any state or federal program? Yes No If Yes, fully explain the details, including date, the state where the incident occurred, the agency taking the action, and the program affected. (attach additional sheets if necessary) Are you charged with a crime right now or have you ever been convicted of a crime (excluding Class C misdemeanor traffic citations)? Convicted means that: 1. A judgment of conviction has been entered against you by a federal, state or local court. It doesn t matter if: a. There is a post-trial motion or an appeal pending, or b. The judgment of conviction or other record relating to the criminal conduct has been expunged or otherwise removed; 1. a. b. 2. A federal, state or local court has made a finding of guilt against you; 2. 3. A federal, state or local court has accepted a plea of guilty or nolo contendere by you, 3. 4. You have entered into participation in a first offender, deferred adjudication or other program or arrangement where judgment of conviction has been withheld. 4. To answer this question, use the federal Medicaid/Medicare definition of Convicted in 42 CFR. 1001.2 as described above, and which includes deferred adjudications and all other types of pretrial diversion programs. A person on deferred adjudication is considered convicted, and therefore barred from providing services under this contract, until successful completion of deferred adjudication. You may be subject to a criminal history check. If you answered Yes to any of the four items above, fully explain the details, including date, the state and county where the conviction occurred, the cause number(s), and specifically what you were convicted of (attach additional sheets if necessary). Signature of Driver After filling out this form, make a copy of this page for your records. Send the original to LogistiCare ITP Program Driver Packet Page 3
Driver Agreement As the approved driver, you agree to the following: 1. Before an approved driver gives a ride, the person getting the ride (rider) must get approval for the ride from LogistiCare (LGTC). The rider must call LogistiCare toll-free at 1-855-687-3255 to get this approval. Without this approval, the driver will not get paid. (The person needing the ride should call toll-free 1-855-687-3255 to set up the ride and get approval for it.) 2. LogistiCare may check the facts the driver has given in this form. 3. The person getting the ride must have their health-care provider sign the Driver Claim Form during the visit. The driver also must sign the claim form and then send it to LogistiCare. The driver cannot get paid without a signed and completed Driver Claim Form. 4. The driver must send the Driver Claim Form to LogistiCare within 30 days from the first trip date written on the claim form. 5. The amount the driver gets reimbursed (paid back) is based on the total mileage of the trip and not on the number of people who are given a ride. 6. If a driver lies, hides facts, or charges the rider any fees, LogistiCare will file charges against the driver for violating federal and state laws. 7. LogistiCare will report to the Internal Revenue Service (IRS) all payments made to a driver. 8. LogistiCare may place a driver s payments on hold until the driver has resolved all his/her outstanding debts with the state of Texas. 9. The driver must not give the name of any rider / client to anyone other than HHSC or LogistiCare. This applies to anyone the driver has given rides to in the past. Information about people covered by Medicaid must be kept private and is protected by both state and federal law. 10. The driver can be a family member, neighbor, or other person who has been approved by LogistiCare to drive someone to their Medicaid health-care visit. The person covered by Medicaid also can be approved as a driver and drive themselves to a health-care visit. 11. The driver will only be paid for mileage LogistiCare has approved for driving someone to their health-care visits. 12. LogistiCare uses an Internet mileage search engine to find out the distance of a trip. The driver will be paid back per mile based on the vehicle mile rate set for state employees by the Texas Legislature that is in effect the date of the trip. 13. To get paid, the driver must be approved and signed up with LogistiCare. The driver will only be paid for rides that have been preapproved by LogistiCare. 14. The driver will comply with the minimum amount of auto liability insurance coverage required by the State of Texas. 15. The vehicle used to transport the member to medical appointments must pass the State of Texas Safety Inspection annually. I, ITP s Name (must match name listed on driver s license), hereby declare that I have read the above terms and conditions of this Driver Agreement, and I understand that I must comply with all the terms and conditions. In addition, the Driver attests that the vehicle they use to transport Medicaid members to medical appointments has a current vehicle registration and Texas state safety inspection. Signature of Driver After filling out this form, make a copy of this page for your records. Send the original to LogistiCare. ITP Program Driver Packet Page 4
Facts About the Driver Fill out entire form and sign it. If a question or answer does not apply to you, write N/A in the space provided. You must sign this page; we will not accept stamped signatures. Use blue or black ink. Facts About the Driver Last Name First Initial: Must match name listed on driver s license. Email: (if you have one) Website address: (if you have one) Phone number: Social Security number: You also must send a copy of your card. Street address: This is where you live. (You must give a street address. PO boxes will not be accepted.) Number Street Suite/Apt # City State ZIP Billing address: This is where you want mail sent. You can give us a PO box for this. Number Street Suite/Apt. # City State ZIP Street address FAX number: (optional) Billing address FAX number: (optional) Driver s License Number: Also send copy of license/temporary license. State Issued (Example: TX): license expires: MM/DD/YYYY Auto insurance policy number: Also send copy of U.S.-issued insurance card. Your name must be listed on card. policy issued: MM/DD/YYYY policy expires: MM/DD/YYYY Important: The name listed on your auto insurance card, driver s license, and Social Security card must be the same. Facts About the Person(s) I Will be Driving: Rider s Name Rider s Medicaid ID # I am related to this rider. (If YES, list relationship) YES NO YES NO YES NO Signature of Driver After filling out this form, make a copy of this page for your records. Send the original to LogistiCare. ITP Program Driver Packet Page 5
Instructions for Filing a Claim When you give someone a ride to a health-care visit, LogistiCare MUST receive your claim form within 90 days of the first date of service written on the form. Make sure your claim form is complete and has: o A LogistiCare Job/Trip Number (This is given to the member when he/she calls LogistiCare for a reservation). o Trip o Health-care Provider Signature o Driver s Signature and If LogistiCare says you can give someone a ride to their health-care visit, that approval does not guarantee you will get paid for that trip. However, you will need that approval if you hope to get paid for the trip. Where to Send Your Forms Driver Sign-Up Forms: LogistiCare Solutions Provider Compliance Department 12234 Interstate 35, Plaza 35 Bldg B Austin, Texas 78753 Driver Claim Forms: LogistiCare Solutions Texas Claims Department 12234 Interstate 35, Plaza 35 Bldg B Austin, Texas 78753 Who to Call (All numbers are toll-free) To set up a trip call: LogistiCare Reservations Department..855-687-3255 To get info about signing up for ITP program call: LogistiCare Compliance Department 877-564-9838 To get help filling out your packet call: LogistiCare Compliance Department.877-564-9838 ITP Program Driver Packet Page 6