CurrentPriority HealthPolicy N/A

Medicaid Mileage Reimbursement Form and Guidance

This document is a Priority Health form and guidance for requesting reimbursement of transportation (mileage) to health care locations for Medicaid members in Michigan. It outlines eligibility requirements, submission instructions, contact information, and the form fields to claim trips.

Policy Summary

PayerPriority Health

PolicyMedicaid Mileage Reimbursement Form and Guidance

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed reimbursement form to Priority Health via postal mail, fax, or email using the contact details on the form.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

365 dayswindow for eligible trips

Postal, fax, emailsubmission methods provided

888.975.8102Member customer service phone

616.464.8905Fax number for submission

reimbursement@priorityhealth.comEmail for submission

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Mileage Reimbursement Coverage Criteria

Mileage reimbursement criteria

Reimbursement is available for qualifying transportation to covered services when ALL of the following are met:

ALL of the following

Trip occurred within the last 365 calendar days.
Transport normally has a monetary cost (routine free transport is not eligible unless special circumstances are demonstrated).
Member went to the nearest provider offering required care unless prior approval was obtained for a more distant provider.
Vehicle used had valid, current automobile insurance.
Driver had a legal driver’s license.
Member did not receive any other payment for the trip (and will report if they do).
No other Medicaid enrollee is claiming reimbursement for the same trip to the same place on the same day.

ALL of the following

Reimbursement is calculated using the member address on file with MDHHS and the trip destination.

Operational note: Trips ordinarily provided free (e.g., by family/friends) are not reimbursable unless the member can demonstrate special circumstances or hardship.

Covered Scenarios and Timeframe

Covered scenariosmixedCovered

No codes listed

inv-03: Eligible trip timeframe

Eligible trip timeframeTrips occurring within the last 365 calendar days

Reference for calculationReimbursement is calculated using the member address on file with Priority Health as documented by MDHHS

Window startTrip date must be within the prior 365 calendar days from submission

Form Submission & Member Support

Documentation Required

Form submission — send completed form by mail, fax, or email

Submit the completed Mileage Reimbursement form to Priority Health using one of the methods listed on the form. The form includes the postal address, fax number, and email for submission.

Postal mail: Priority Health Transportation Coordinator, 1231 East Beltline NE, MS 1145, Grand Rapids, MI 49525
Fax: 616.464.8905
Email: reimbursement@priorityhealth.com

Note

Member support — call or send a secure message

If you have questions about the form or the reimbursement process, contact Member Customer Service at the number provided or send a secure message via the member portal.

Phone: 888.975.8102 (TTY: 711); hours: Mon–Thu 7:30 AM–7:00 PM, Fri 9:00 AM–5:00 PM, Sat 8:30 AM–12:00 PM ET
Or sign in to the member account at priorityhealth.com and send a secure message

Eligible Trip Definitions & Restrictions

inv-06: Eligible trip

Definition of eligible tripTrip to a health care center, pharmacy, or appointment for a covered service that occurred within the last 365 calendar days and generally had a monetary cost.

Examples of destinationsTrips include visits to medical provider offices, pharmacies, and appointments for covered services (e.g., physical therapy).

Cost requirementTrip normally has a monetary cost; routine free transport is not eligible unless special circumstances are demonstrated.

Address used for calculationReimbursement is calculated using the member address on file with Priority Health (MDHHS documentation).

inv-07: Restrictions on reimbursement

Free tripsTrips that are usually free are not reimbursable unless the member can demonstrate special circumstances or difficulties.

Nearest appropriate providerReimbursement is for travel to the nearest provider offering the needed care unless prior approval was obtained to go to a more distant provider.

Vehicle and driver requirementsVehicle used must have valid, current automobile insurance and the driver must have a legal driver’s license.

No duplicate or other paymentsMember must not have received any other payment for the trip and no other Medicaid enrollee may claim reimbursement for the same trip to the same place on the same day.