How to Fill Out the South Dakota NEMT-970 Travel Reimbursement Form

South Dakota’s NEMT-970 form is the day-trip reimbursement claim Medicaid recipients use to get paid back for mileage and other travel costs when they drive to a medical appointment outside their city of residence. The medical provider fills out the top half at your appointment, you complete the bottom half with your trip and payment details, and the completed form goes to the Department of Social Services within six months of the date of service.¹

The form is for same-day round trips. Overnight travel uses a separate form, the NEMT-971, and only qualifies for lodging or meal reimbursement when you need specialty care at least 150 miles from your city of residence.¹

Before Your Appointment

Print the NEMT-970 from the DSS website and take it with you. The provider has to complete and sign their section, so having the form in hand at check-in avoids a second trip or a chase-down call afterward. The form itself is blunt about this: “All fields MUST be completed.”² A missing signature or blank NPI number is enough to stop your claim.

Check two eligibility points before you go. First, your Medicaid coverage has to be active on the day you travel; trips before your eligibility start date won’t be reimbursed even if you enroll later.¹ Second, the program only reimburses travel to the closest provider capable of the care you need. If you want to see someone farther away, get a written referral from a medical provider explaining why the nearer option won’t work. Without that referral, the state will only pay mileage to the closer facility.³

Traveling out of state adds one more requirement: an Out of State Prior Authorization must be in place for your travel dates, and the provider will confirm this on the form.² Get that squared away first.

What the Provider Fills Out

Hand the form to the front desk or your provider when you arrive. Their section captures the appointment date and time, facility name, phone number, address, and both the billing and service NPI numbers. They also state the specific purpose of the visit and confirm whether the service is Medicaid-covered. For pharmacy pickups, equipment fittings, or optical supplies, the form asks for the prescribing doctor’s name and whether a delivery option was unavailable.²

Two yes-or-no boxes sit in this section: whether a referral from your Care Management Provider is on file, and (for out-of-state trips) whether the Out of State Prior Authorization covers your travel dates. A doctor, nurse, receptionist, or pharmacist signs and dates this section. That signature is what makes the form processable.

Multiple Appointments on One Trip

The NEMT-970 has room for only one provider. If you saw two or more facilities on the same trip, print the NEMT Appointment Verification Form (NEMT-973) and have each additional facility sign that form, then submit it alongside your 970.²

What You Fill Out

After the appointment, complete the bottom half yourself (or a parent or guardian does it for a minor). Start with trip information: departure date, return date, whether the recipient is currently an inpatient, and whether this trip continues an earlier one. Then enter recipient details: full name, phone number, Medicaid number, date of birth, and mailing address. There is space for up to three recipients if you transported other Medicaid-eligible passengers to the same appointment.

The Travel Points section is where you log your route. Enter your starting city and state, ending city and state, and the mode of travel for each leg: personal vehicle, bus, transit provider, IHS van, Shriner’s van, ambulance, or other. Do this for both directions. If you want mileage reimbursement, mark “Yes” and note whether the trip involved stops in more than one city. If a driver from outside your city of residence transported you because of a medical necessity, check that box and attach supporting medical documentation.²

Log any miscellaneous costs: parking, public transit fares, luggage fees. Enter the type of expense and the dollar amount. If another organization helped pay for the trip, use the Travel Assistance section to list the organization’s name, contact information, the type of assistance, and the amount. South Dakota Medicaid pays as a secondary source, so outside help reduces what the state owes you.⁴ Skipping this disclosure is a common reason claims get denied.

Finish with the Payment Provider section (the payee’s provider number, name, and mailing address), then sign and date. Keep a copy before it leaves your hands.

How Much You Get Back

Private vehicle mileage is reimbursed at $0.70 per mile, a rate effective since December 2025, and that rate covers both directions of the trip.⁵ Parking, public transit, and luggage fees come back at whatever amount you enter in the miscellaneous section. If a medically necessary escort traveled with you on an overnight trip, their lodging and meals can be reimbursed too, but that scenario uses the NEMT-971, not the 970.¹ A long day trip alone does not qualify for meal money.

Submitting the Form

You have six months from the date of service to file, and two ways to do it.¹

Online Portal

The DSS runs an NEMT portal at dss.sd.gov/nemt where you can submit claims, track their status, and update banking and personal information. Enroll and select a payment option before your first submission.¹ For online claims, the workflow shifts slightly: instead of the provider completing the top of the NEMT-970, you print the NEMT Appointment Verification Form (NEMT-973), have the facility sign that, then upload a scan or photo of the signed verification along with your claim details in the portal.

By Mail

To file on paper, send the completed NEMT-970, with the provider’s signature, to:

South Dakota Department of Social Services
Division of Medical Services
700 Governors Drive
Pierre, SD 57501

Include the NEMT-973 if you had more than one appointment on the trip, plus any supporting medical documentation. Confirm the provider section is fully signed and that your starting and ending cities match the facility address before you seal the envelope.

Getting Paid

Payment comes as either direct deposit or a MasterCard-branded debit card, whichever you selected at enrollment. Paper checks aren’t offered.⁴ Claims are processed in the order received, and DSS does not publish a guaranteed turnaround; the online portal lets you check status rather than guessing.

Why Claims Get Denied

Most denials come back to incomplete paperwork, and the provider section is where things fall apart most often: a missing signature, a blank NPI, or a vague “checkup” instead of a specific purpose of visit. Other frequent problems:

Medicaid coverage was not active on the date of service.
You traveled to a farther facility with no written referral justifying it.
An out-of-state trip lacked an approved Out of State Prior Authorization.
The claim arrived more than six months after the service date.
You received outside help paying for the trip and didn’t disclose it.

Catch errors before submitting when you can. If you notice after the fact that the provider section is incomplete, contact the facility and ask them to complete a corrected form or a separate Appointment Verification Form.

If Your Claim Is Denied

The denial notice explains the reason and your appeal rights. You can request a fair hearing through the Office of Administrative Hearings, and your request must include specific information about why you disagree with the decision.⁶ Hang on to your original NEMT-970, the signed provider section, any NEMT-973 verifications, and every piece of correspondence from the department. Those become your evidence.

1
South Dakota Department of Social Services. Medicaid Non-Emergency Medical Travel (NEMT)
2
South Dakota Department of Social Services. South Dakota Medicaid Non-Emergency Medical Travel (NEMT) Reimbursement Form – Day Trip
3
South Dakota Department of Social Services. Medicaid Recipient Transportation
4
South Dakota Department of Social Services. South Dakota Medicaid Non-Emergency Medical Travel Program
5
South Dakota Department of Social Services. Transportation Services Fee Schedule
6
South Dakota Department of Social Services. Reconsideration Reviews, Coverage Requests, and Fair Hearings