How to Fill Out and Submit the Mississippi Medicaid Transportation Reimbursement Form

To get mileage reimbursement from Mississippi Medicaid for driving yourself to a covered medical appointment, you fill out and submit Modivcare’s Mileage Reimbursement Trip Log. But the form is only the last step. Before you can use it, you have to call Modivcare at 1-866-331-6004 and get a trip number for the appointment. Without that number, the form won’t be paid.

Call Modivcare Before Your Appointment

This is the step most people miss. Call 1-866-331-6004 at least three business days before your medical appointment to schedule the trip and get a trip number. If you call with less notice and the trip isn’t urgent, Modivcare may ask you to reschedule the appointment.¹

There is one exception to the three-day rule: trips tied to a hospital discharge or a return from emergency services do not require advance scheduling.²

Write the trip number down the moment you receive it. It goes on the Trip Log, and the form cannot be processed without it.³

Who Can Use This Form

Mississippi Medicaid’s Non-Emergency Transportation (NET) program covers the trip only when all of the following are true: the appointment is for a Medicaid-covered service with a Medicaid-enrolled Mississippi provider, you’re in a Medicaid category that includes NET benefits, you have a medical need for transportation, no one else can take you, and driving yourself is the most economical option available.²

Several Medicaid categories are excluded from NET entirely: the Family Planning Waiver, Qualified Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary (SLMB), Qualified Working Disabled Individuals (QWDI), and Qualified Individual (QI-1). People in those categories cannot use the mileage reimbursement process.²

One more boundary. The Modivcare process on this page applies to Fee for Service Medicaid. If you’re enrolled in the Mississippi Coordinated Access Network (MississippiCAN) through a managed care plan such as TrueCare, Molina Healthcare, or Magnolia/Centene, your transportation runs through that plan’s own broker, not Modivcare. The Mississippi Division of Medicaid’s covered services page lists each plan’s transportation number.⁴

Where to Get the Form

The form is the Mileage Reimbursement Trip Log, available on Modivcare’s Mississippi facility resources page as a printable PDF, a fillable digital version, and a Spanish-language version. The same page carries the Mileage Reimbursement Program Instructions and Trip Log Instructions, which explain each field.⁵ If you don’t have internet access, call 1-866-331-6004 and ask for a paper copy.

If you have an older form from MTM, the previous NET broker, throw it out. Modivcare took over Fee for Service transportation in June 2024, and only the current Modivcare version will be processed.⁶

Filling the Form Out

Fill in every field except the provider’s signature before you leave for the appointment. Each trip entry needs:

The trip number Modivcare gave you on the phone.
The date of the trip.
Your name and Medicaid ID number as they appear on your Medicaid card.
The starting address and the medical facility’s address, so Modivcare can verify the mileage.
The miles driven.

One form can hold more than one trip, so you don’t need a new sheet for every visit. But each form covers only one driver. If different people drive you to different appointments, use a separate form for each driver.³

Leaving the trip number or date blank is the most common reason a reimbursement is denied or delayed. Double-check both before you leave the house.³

Get the Provider Signature at the Visit

Take the partially completed form into the appointment. Before you leave the office, ask your doctor, counselor, or an authorized staff member to sign the “Physician/Clinician Signature” line. That signature is Modivcare’s confirmation that you actually attended. Without it, the form is incomplete and will not be processed.³

Don’t walk out planning to come back for the signature later. Some offices are reluctant to sign days after a visit, and the trip back is wasted time.

Submitting It and Getting Paid

Submit the form the way the printed instructions on the form itself direct, typically by mail or fax.³ Send it in soon after the appointment rather than letting completed forms pile up, and keep a copy for your records.

Modivcare verifies your trip against the authorization on file and the provider’s confirmation, then mails your reimbursement. As of January 1, 2024, the rate was 67 cents per mile, which Modivcare adjusts to match the IRS standard mileage rate.³ The IRS resets that rate every year, so call 1-866-331-6004 if you want to confirm the amount in effect for your trip date.

If anything is missing, Modivcare will contact you for corrections and payment waits until the form is clean. A trip number, a date, and a provider signature on every entry is the whole trick.

Phone Numbers to Keep

Modivcare splits its Fee for Service lines by purpose:

Schedule a trip or ask about mileage reimbursement: 1-866-331-6004
Late or no-show ride: 1-866-334-3794
Member complaints: 1-866-381-4853
Transportation provider complaints: 1-866-381-4852¹

If you’re on a managed care plan rather than Fee for Service, none of these numbers apply to you. Use the broker number listed for your plan on the Division of Medicaid’s covered services page.⁴

1
Modivcare. Mississippi Medicaid
2
Mississippi Division of Medicaid. Mississippi Administrative Code Title 23, Part 201 – Transportation Services
3
Modivcare. Mileage Reimbursement
4
Mississippi Division of Medicaid. Covered Services
5
Modivcare. Mississippi Facility Resources
6
Mississippi Division of Medicaid. Modivcare to Replace MTM as the New Non-Emergency Transportation (NET) Broker