How to Complete and Submit the MN Medical Assistance Mileage Reimbursement Form

To get paid back for driving yourself to a covered appointment, complete the Minnesota Medical Assistance mileage reimbursement form from your county or tribal human services agency, have the provider sign for each visit, attach any parking or other receipts, and submit it to the county within its filing deadline. The current rate for members who drive themselves, or who are driven by a family member, neighbor, or other person with a vested interest, is $0.22 per mile as of April 1, 2026, and it adjusts every quarter based on fuel costs.¹

Where to Get the Form

The form comes from your local county or tribal human services agency, not from a central state office. Some counties label it a “Request for Medical Trip Reimbursement.” The format varies slightly by county, but the information asked for is the same statewide. You can usually pick it up at the county office, request it by phone, or download it from the county’s human services website. This is true whether you are fee-for-service or enrolled in a managed care plan; personal mileage reimbursement runs through the county in either case.²

One form covers one calendar month. If you had trips in March and April, that’s two forms.¹

What to Record for Each Trip

For every appointment, the form asks for:

Your full legal name and date of birth as they appear on your Minnesota Health Care Programs card.
The date you traveled.
The scheduled appointment time.
The address you traveled from, usually your home.
The provider’s name and full street address.
Round-trip miles. Record your odometer before you leave and when you return, or use an online mapping tool for the most direct route. Reimbursement covers only that direct route, starting with the first mile you are in the vehicle.
A short description of the care, such as “dental cleaning” or “physical therapy.”

Write legibly, and double-check your totals. Blank fields and transposed numbers are the fastest way to stall your payment. Keep a copy of every form you send.

Provider Signature on Every Line

Each trip has to be verified by the provider. The healthcare professional or an authorized clinic representative signs the line for that date of service, confirming you actually attended. Without the signature, the county will not reimburse that trip. If you forgot to get one at the visit, call or return to the clinic and ask whether they can supply written verification after the fact.

Signing the Attestation

At the bottom, you sign a declaration under penalty of law that the information is accurate, that no one else has already paid for the travel, and that you agree to the reimbursement guidelines. False information can cost you your benefits and carry legal consequences, so review every date and mileage figure before signing.

Parking, Tolls, Meals, and Lodging

Mileage is not the only travel cost covered. When parking, tolls, meals, or lodging are necessary to reach a covered health service, those are reimbursable too. Attach itemized receipts for each expense on the same form as your mileage claim for that trip. Parking meters are the one exception and do not require a receipt. Parking and meal receipts must show the date and time.³

Parking is paid at actual cost, but the program expects you to pick the most cost-effective option. If you are at the same facility several times a week, a weekly or monthly pass may be cheaper than the daily rate, and the county may push back on repeated daily charges when a pass was available.³ Lodging and meal reimbursement mostly comes up for long trips, such as a rural member traveling to a specialist in the Twin Cities.

Where to Send It and by When

Send the completed form to your local county or tribal human services agency, not to a state office.² The mailing address, fax number, and email vary by county, so confirm with your caseworker or on the county’s human services website. Most counties accept mail, fax, or email; some also allow in-person drop-off. If you fax or email, make sure the scan is sharp enough to read a signature and an odometer figure.

File promptly. County agencies set their own deadlines for how quickly you have to submit after a trip, and at least some counties require the form within 60 days. Miss that window and the claim may be denied outright. The reliable habit is to fill out the form the day of each appointment, get the provider signature while you are still at the clinic, and submit at the end of each month.

Because the per-mile rate resets on January 1, April 1, July 1, and October 1, check the DHS NEMT provider manual page before you calculate what you expect back. A trip in December and a trip in January can reimburse at different rates.

After You Submit

The county reviews your log against medical claims on file to confirm the appointments happened and the services were covered. If everything matches, the county issues payment, usually as a paper check to the address on file. Some counties may offer direct deposit. Processing times depend on the county and its claim volume.

If something is off, the form comes back for correction. The common reasons a claim stalls or gets denied:

Missing provider signature. The single most frequent problem.
Mileage that doesn’t match the route. Claiming 50 miles for a provider 10 miles away will get flagged.
Travel to a service not covered under your plan.
Filing after the county’s deadline.
Missing receipts for parking, meals, or lodging. Those amounts will be removed from your payment.

Appealing a Denial

You can appeal a denied mileage claim. Minnesota Medical Assistance members can request a state fair hearing within 30 days of the denial notice. With good cause for the delay, that deadline extends to 90 days, and the DHS appeals office decides whether the reason qualifies.⁴

File using the Appeal to State Agency form (DHS-0033). You can submit online and mail it to the DHS State Appeals Office at PO Box 64941, St. Paul, MN 55155-0941, mail it to your county or tribal agency, or deliver it in person to the DHS Information Desk at 444 Lafayette Road North, St. Paul, MN 55101. Phone appeals are also accepted.⁴ Managed care members who get a denial from their health plan can also request a state fair hearing within 30 days of the plan’s notice.⁵

If you file before the effective date on the denial notice, your benefits can continue while the appeal is pending. If the situation is urgent, such as a denial that would keep you from ongoing treatment, ask for an expedited appeal. DHS must decide within three working days of receiving an expedited request that meets its criteria.⁴

1
Minnesota Department of Human Services. Nonemergency Medical Transportation (NEMT) Services
2
Minnesota Department of Human Services. Local County or Tribal Agency Nonemergency Medical Transportation
3
Minnesota Department of Human Services. Access Services Ancillary to Transportation
4
Minnesota Department of Human Services. MHCP Appeals – Eligibility Policy Manual
5
Minnesota Department of Human Services. Grievance, Appeal, and State Fair Hearing Process