To claim mileage on the MaineCare mileage reimbursement form, call your regional transportation broker before your appointment, fill in your member and driver information, log each trip with round-trip miles, get the provider’s original ink signature at the visit, and mail the form to your broker before their deadline. MaineCare pays $0.50 per mile for members who drive themselves or ride with a friend, family member, or neighbor to a covered medical appointment.
Find the Broker for Your County
Maine splits non-emergency transportation among three brokers, and each one uses its own form, submission channels, and deadline. Figure out which one covers you before anything else.
- Modivcare covers Aroostook, Hancock, Washington, Cumberland (except Brunswick and Harpswell), Androscoggin, Franklin, Oxford, and York counties.
- Penquis covers Penobscot, Piscataquis, Kennebec, and Somerset counties.
- MidCoast Connector, run by Waldo Community Action Partners, covers Knox, Lincoln, Sagadahoc, and Waldo counties, plus Brunswick and Harpswell.
Broker contacts are listed on the Maine DHHS transportation page, or you can call MaineCare Member Services and ask.1Maine Department of Health and Human Services. Non-Emergency Transportation
Call Your Broker Before You Go
This step is where most denials start. If you don’t call your broker to register the trip in advance, the claim will be rejected no matter how clean the paperwork looks.2Waldo Community Action Partners. MaineCare Transportation Have your MaineCare ID ready, along with the provider’s name and address and the appointment date and time. Most brokers want at least two full business days of notice. Out-of-state appointments need at least seven days because they require prior authorization.
Ask on the same call which version of the form your broker wants. Modivcare posts forms on the MyModivcare member portal.3Modivcare. Maine Member Resources Waldo CAP hosts the MidCoast Connector form on its site. Penquis has its own mileage log available by phone or download. DHHS also publishes a general form, but your broker may insist on their own.4Maine Department of Health and Human Services. MaineCare Mileage Reimbursement Form Print the blank form and take it with you.
Filling Out the Form
Layouts vary a little between brokers, but every version asks for the same four blocks of information.
Member Information
Write your full name, MaineCare ID, physical address, phone number, and date of birth. Check the address-update box if anything has changed since your last claim. Email is optional. Sign and date this section yourself, or have your authorized representative or guardian sign and check that box.5Waldo Community Action Partners. MaineCare Self Drive/FFN Mileage Reimbursement Form
Driver Information
Enter the driver’s full name, mailing address, phone number, driver’s license number, and license expiration date. The driver signs and dates the form. Check the “new driver” box if this driver or their information hasn’t appeared on a previous claim. If you drove yourself, put your own details here.
Trip Details
Log each appointment on its own line: date of service, appointment time, and round-trip miles from your home to the provider and back. Use your odometer or a mapping tool, because the broker will check. One form can hold up to seven visits when they are all at the same provider and location, which helps with recurring care like dialysis or physical therapy.5Waldo Community Action Partners. MaineCare Self Drive/FFN Mileage Reimbursement Form Use a separate form for each provider if you see two different providers on the same day.
Provider Information and Signature
Write the provider’s name, office address, and phone number. Then get the provider or an authorized staff member to sign each trip entry in blue or black ink before you leave. Signature stamps are not accepted, and neither are photocopies.5Waldo Community Action Partners. MaineCare Self Drive/FFN Mileage Reimbursement Form Coming back for a signature later adds weeks to the process.
Where to Send the Completed Form
Each broker takes submissions differently.
- Modivcare: mail to 798 Park Avenue NW, Norton, VA 24273; fax to 866-528-0462; or email claims@modivcare.com.6Modivcare. Modivcare Mileage Reimbursement Letter Instructions – Maine
- Penquis: mail to Penquis Transportation Brokerage, PO Box 1162, Bangor, ME 04402, or email transportationfiscal@penquis.org.7Penquis. Mileage Reimbursement Instructions
- MidCoast Connector: mail or drop off at the Waldo Community Action Partners office. Fax and email are not accepted.2Waldo Community Action Partners. MaineCare Transportation
Every signature has to be original, so photocopied signatures fail across all three brokers.7Penquis. Mileage Reimbursement Instructions Keep a photocopy of the completed form before you send the original.
Submission Deadlines
Deadlines are enforced strictly. A form that arrives one day late is denied.
- Penquis: 30 days from the earliest appointment date on the form.7Penquis. Mileage Reimbursement Instructions
- MidCoast Connector: 60 days from the appointment date. If the form comes back for corrections, you get 60 days from the return date to resubmit.5Waldo Community Action Partners. MaineCare Self Drive/FFN Mileage Reimbursement Form
- DHHS standard form (used by Modivcare and others): 90 days from the earliest travel date on the form.4Maine Department of Health and Human Services. MaineCare Mileage Reimbursement Form
Submit within a week or two of each visit. That leaves a cushion for mail delays or a returned form that needs fixing.
What You’ll Get Paid and When
The rate is $0.50 per mile for self-drive and friend, family, or neighbor transportation.2Waldo Community Action Partners. MaineCare Transportation Miles cover the round trip. A 40-mile-each-way appointment pays 80 miles, or $40.00.
A complete, error-free form usually processes in two to four weeks. Payment normally arrives as a paper check mailed to the address on file. Some brokers offer direct deposit, so ask when you register the trip. If a month passes and nothing comes, call your broker’s customer service line and ask whether the claim was approved, denied, or held for more documentation.
Why Claims Get Denied
Most rejections come from a short list of avoidable mistakes.
- You didn’t call the broker before the appointment to register the trip.2Waldo Community Action Partners. MaineCare Transportation
- The provider signature is missing, stamped, or photocopied.
- A required field is blank, even something small like a driver’s license expiration date.
- The form arrived after the broker’s deadline.
- Your MaineCare coverage wasn’t active on the date of service.
- The broker contacted the provider and couldn’t verify you attended.
Read every line before you seal the envelope. A missing date of birth or an unsigned driver section is the kind of small miss that adds a month to your wait.
Who Qualifies
Reimbursement is for MaineCare members traveling to a covered, non-emergency medical appointment using the least costly appropriate mode of transportation, which usually means a personal vehicle rather than a hired medical transport.1Maine Department of Health and Human Services. Non-Emergency Transportation The driver can be you, a relative, a friend, or a neighbor, as long as they have a valid license.8Modivcare. Maine Facility Resources The visit has to be with a MaineCare-enrolled provider for a service your plan covers. Trips to providers who don’t take MaineCare, or for services MaineCare doesn’t cover, aren’t reimbursable.