WV DFA-NEMT-1a 2009-2025 free printable template
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WEST VIRGINIA DEPARTMENT OF HEALTH AND HUMAN RESOURCES
SUPPLEMENT TO APPLICATION FOR NEXT REIMBURSEMENT PROGRAM
This supplemental sheet is used with the DFA-NEMT-1 and contains space for 3 additional
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How to fill out modivcare wv mileage reimbursement
How to fill out WV DFA-NEMT-1a
01
Obtain the WV DFA-NEMT-1a form from the appropriate West Virginia Department of Health and Human Resources website or office.
02
Fill out your personal information at the top, including your full name, address, and contact details.
03
Provide information regarding your medical needs by detailing the transportation services required.
04
Include your Medicaid number and any other relevant identification numbers if applicable.
05
Indicate if you require transportation assistance for recurring medical appointments or one-time services.
06
Complete the sections regarding the availability of transportation and any other services you may need.
07
Review the form for completeness and accuracy before submission.
08
Submit the completed form to the designated office or mailing address for processing.
Who needs WV DFA-NEMT-1a?
01
Individuals who require non-emergency medical transportation services covered by Medicaid in West Virginia need to fill out the WV DFA-NEMT-1a form.
02
This includes patients who have appointments for medical services, treatments, or therapies and do not have an accessible means of transportation to get to these appointments.
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People Also Ask about
How much does modivcare pay per mile in Florida?
You can also contact the ModivCare Reservation Line at 1-866-306-9358 to request blank copies of the form. Your health care provider must sign the form as proof that you were at your appointment. You will not receive payment for your trip unless your form is complete. The rate is $0.54 per mile.
How long does it take to get the gas reimbursement from modivcare?
The payment will be mailed within 30 days of the ModivCare Claims Department receiving your completed reimbursement form.
What is the phone number for WV travel voucher?
Please call: 1-888-513-0703.
How much does modivcare pay per mile in Virginia?
Reimbursed at a rate of $0.50 per traveled mile, personal satisfaction of helping others, FREE Emergency Kit, Modivcare driver training, etc. What are the requirements to be a Volunteer Driver? The requirements are: At least 18 years of age.
What is the WV mileage rate?
Effective January 1, 2022, the state mileage reimbursement rate increased to 58.5 cents per mile. Therefore, the mileage reimbursement rate for claimants is 58.5 cents per mile as of January 1, 2022.
How much does modivcare pay per mile in SC?
You will not receive payment for your trip unless your form is complete. The rate is $0.54 per mile. The distance will be the number of miles from your home to your medical appointment. The miles will be given to you during your reservation phone call.
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What is WV DFA-NEMT-1a?
WV DFA-NEMT-1a is a form used by the West Virginia Department of Health and Human Resources to report non-emergency medical transportation (NEMT) services provided to eligible Medicaid recipients.
Who is required to file WV DFA-NEMT-1a?
Transportation providers that offer non-emergency medical transportation services to Medicaid recipients in West Virginia must file the WV DFA-NEMT-1a form.
How to fill out WV DFA-NEMT-1a?
To fill out the WV DFA-NEMT-1a, providers must provide information about the recipient, the transportation services provided, dates of service, and any relevant billing details according to the instructions outlined by the West Virginia Department of Health and Human Resources.
What is the purpose of WV DFA-NEMT-1a?
The purpose of WV DFA-NEMT-1a is to ensure accurate reporting and reimbursement for non-emergency medical transportation services rendered to eligible Medicaid recipients in West Virginia.
What information must be reported on WV DFA-NEMT-1a?
The information that must be reported on WV DFA-NEMT-1a includes the recipient's identification, dates and times of transportation services, origin and destination addresses, mode of transportation, and any relevant billing details.
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