This page is left blank intentionally2

What should I do if I have an emergency?Call 911What is Non-emergency Medical Transportation?Non-Emergency Medical Transportation (NEMT) is alimited transportation benefit that is provided toMedicaid members (Husky A, C, D and limited benefitmembers) who have no other means of transportation,to a Medicaid covered Medical, Behavioral Health, orDental service.A member can go to any provider they choose that isin the network. However, transportation can only beprovided to the closest appropriate Medicaid coveredservice provider within a 15 mile radius. In somecases you may be able to be transported to a providerwho is further away. A Closest Provider CertificationForm (CPC) form may be required from your medical,dental or behavioral health provider in order toarrange for a ride. The CPC form can be found on er/enus/downloads3

Rides are not provided to pick up prescriptionsor medical equipment that does not need to befitted.There are multiple kinds of transportationavailable.If you, a family member or friend has a car andare able to drive you to your appointment butcannot afford to pay for gas you may be eligibleto be paid for gas. If you are able to ride thebus a bus pass may be provided. If you are notable to ride the bus then a ride with the type ofvehicle based on your medical andtransportation needs will be scheduled. Thismay be a car, wheelchair accessible vehicle,non-emergency ambulance or other publictransportation. Your doctor may need to fillout a Physician Transportation Restriction(PTR) form . The PTR form can be found mber/enus/downloadsThere are multiple ways to request a ride / make areservation.You can request a ride by calling LogistiCare SolutionsLLC at (888-248-9895) Monday through Friday4

between 7:00 a.m. and 6:00 p.m. Rides on mass transitshould be requested at least 5 business days beforeyou need it to allow for delivery of tickets/ passes/tokens. For other types of transportation, the requestmust be made a minimum of 2 full business daysbefore the. You can schedule a trip up to ninety (90)days before your appointment. You may reserve up tothree (3) appointments per phone call to LogistiCare.You need to call no laterthan:Monday at 6pmWednesday at 6pmThursday at 6pmIf you have anappointment on:WednesdayFridayMondayIf an urgent condition should arise, you may request aride calling the reservation line with less than the 2business days, at any time or day. An urgent triprequest is when a medical, dental or behavioral healthprovider determines that you must receive services inless than 2 business days (today or tomorrow).LogistiCare will contact the provider to confirm yourappointment is urgent and not routine.Discharges from a hospital or other facility can also bearranged in less than the 2 business day requirement,24 hours a day. Please note, it may take up to 3 hoursto make the arrangements.5

You may also request a trip using the onlinetriprequestportal(MemberServicesWebsite): isticare.comOnce you register on the website, you can use itto make ride requests (at least 2 business daysin advance) or you may continue to call in yourrequest. Depending on your personal situation, differentforms may need to be completed.Physician Transportation Restriction Form(PTR) May be when a member has a medicalneed to travel by a mode other than MassTransit.Closest Provider Certification Form (CPC)May be when there is a medical need to travelpast the fifteen (15) mile radius limit.Companion Referral Form (CRF) May beneeded when a member has a medical need tohave someone travel with them to a Medicaidcovered service.Each form can be downloaded from theLogistiCare /ctmember/enus/downloadsYou can find out the status of your form(s) approval bycalling: 888-248-9895 and choosing option 2.6

Forms must be signed by a licensed treatmentprofessional (MD, LCSW, LMFT, APRN, RN etc.).Signatures from, Certified Nursing Assistants, PatientTechs, Receptionist, Medical Assistants, etc. are notacceptable. Information on the form needs to berefreshed per the guideline indicated on each form orsooner if conditions change.A parent, guardian, or caregiver isrequired to travel with any child under 16 years ofage. Parents may fill out, sign and return the ParentConsent to Travel Form to LogistiCare to allow theirchild who is 12-15 years old to ride without them. Aparent/guardian must ride with their child who isunder the age of 12. Any child who behavesinappropriately while riding alone, will need to beaccompanied by an adult for future rides.A medically required escort/aide/assistant/companion may ride with you if you need help. Yourhealthcare provider will need to fill out and submit theCompanion Referral Form (CRF). A person who yourhealthcare provider says is needed for theappointment may ride with you. For example, asibling and/or parent for family counseling.Your newborn or nursing infant may ride with you.Except as stated above, no other person(s) mayaccompany the member who is being transported toor from a Medicaid-covered service.7

Other people that can request a ride for you:A relative, a caregiver, and healthcare providermay call on your behalf to requesttransportation. CT Behavioral HealthPartnership, CT Dental Health Partnership andCommunity Health Network of CT may alsoassist you in requesting your transportation.Providers such as hospitals, dialysis centersand nursing homes may make a reservation foryou. Facility requests may be submitted online through the Facilities Service Web portal orby phone.When you call LogistiCare to request a rideor to make a reservation, be sure to havethe following information available: Your Medicaid / Client identification (ID)number, Name, Date of Birth, Address, andPhone NumberThe address where you will be picked up if it isdifferent than your home address on file withDSS.Date and time of your appointmentName, Phone Number and Exact Address ofHealthcare Provider (including floor, suite ordoor number) you are going toAny other information that will assist in asuccessful trip such as if you will be travelingwith an aide/companion, type of wheelchair,8

other medical equipment you will have withyou, etc.You will know if you are approvedfor NEMT when you call LogistiCare to ask foryour status or a LogistiCare staff person calls toconfirm your appointment. 888-248-9895You will know you are denied forservices when you call LogistiCare to askabout your status or you receive a Notice of Action(NOA) letter informing you that youwere denied. With the denial, you will receiveinstructions on how to challenge the denial bysubmitting a request for an Administrative Hearing toquestion the decision. This process is called “Filing anAppeal”. If you do not submit the request for anAdministrative Hearing paperwork within 60 daysfrom the date of the notice on the NOA letter you willlose your right to challenge the denial.What you need to know about your ride The transportation provider will pick you upbetween 15 minutes before and 15 minutes after yourscheduled pickup time. You must be ready 15 minutesbefore your scheduled pickup time. You must enter thevehicle immediately upon its arrival. When you enterthe vehicle as soon as it arrives, not only do you helpthe driver stay on time for everyone, but it allows forpossible traffic delays.9

Please wait in a safe area where you can seewhen the provider has arrived. If the ride is more than15 minutes late you may call the “Where’s My Ride”number (1-800-592-4291) to ask for an update onyour ride.Remember: You will need tobring your own equipment needed to travel such as acar seat or wheelchair.You may be sharing a ride with anothermember who is traveling to and from the samearea as you. Shared rides with other Medicaidmembers are allowed. If there are specialhealth circumstances which prevent you fromsharing a ride with other individuals please tellus when you call to schedule your ride. Yourhealth care provider will need to note this onthe Physician Transportation Restriction form(PTR) so that you will not be scheduled for ashared ride.All riders should be thoughtful of anyadditional passengers. You may not bringalcohol, drugs, or weapons in the vehicle. Youcannot smoke, eat or drink while in the vehicle.You must use your seatbelt while traveling.10

You will be asked to sign the driver’s log after you aredriven to your drop off location. You should sign onlyfor the trip that you just received. If you have a returntrip, you will sign for that trip after it is completed.This is used to document that the trip was provided toyou so that the provider can get paid.If you do not have a prescheduled return trip time, youmust call the “Where’s My Ride? Line at: 1-800-5924291 to let them know when you will be ready. Yourride should arrive within 1 hour of your call.The driver has rules to follow too:All drivers and cars must be properly licensed andinsured. Drivers must follow all the normal rules ofthe road including not using a cell phone without ahands free device unless the vehicle is parked.Drivers may help you get from the outside door ofwhere you are picked up to the vehicle and to theoutside door of where you are going if you ask fortheir help. The amount of assistance you receivedepends on the type and level of service you receive.Drivers must not smoke while you are in thevehicle. Drivers should reduce the volume on the radioif you request them to. They should also maintain theair-conditioning or heat at a reasonable temperature.Drivers must secure passengers who are in awheelchair as appropriate for safe travel in the11

vehicle. They must store any unoccupied wheelchairsor other medical equipment safely. Drivers must waitup to 15 minutes after the scheduled pick up time foryou to enter the vehicle.When there is a snowstorm or the weatheris bad:If you do not feel it is safe to be on the road youmay decide to reschedule your appointment.Please contact the medical provider you havean appointment with and LogistiCare toreschedule your appointment for another day.Check with the provider that you havean appointment with to make sure they havenot closed due to the weather. If they have,please call LogistiCare to tell them that you willnot need the trip that day.If a town closes school for the day or hasan early dismissal due to weather, kids will notbe transported to the after school treatmentprogram if the schools in the town they live inare closed or the schools in the town theprogram is located are closed.12

Every effort is made to continue to operatetransportation services during bad weather howeverdelays can be experienced and cancelations may occurdue to unsafe travel conditions. In severe weather,transportation is prioritized to ensure those most atrisk can get the care they need. This typically includesmembers who need to get to dialysis, radiation,chemotherapy treatment and urgent care.If you are not able to make yourappointment and need to cancel orreschedule your ride:Please call LogistiCare at 888-248-9895 to cancelyour trip even if it is a bus ride or gas reimbursement.We ask that you cancel a ride when someone isscheduled to pick you up at least 24 hours (or as soonas possible before the pickup time includingweekends).If your appointment time or day has changed, pleasecall LogistiCare at 888-248-9895 to request thechange as soon as possible.If you have a complaint:You or your representative can make a complaintthroughthewebsite, by phone888-248-9895 or by mail. A complaint can be aboutmany different things like a late pick up, the conditionof the car, behavior of another passenger,13

courtesy of the call center staff.Please have thefollowing information ready to put in your complaint: Your name Your client identification number Date of the trip Trip number A description of the problem Any additional information that can help usinvestigates the problem (e.g. Name of theTransportation Provider).You will receive a call/written response withinOne (1) to three (3) business-days dependingon what kind of complaint it is. You must alsoask for a call back in order to receive one.NEMT Services are based on thedetermination of Medical Necessity.Medical Necessity is:Those health services required to prevent,identify, diagnose, treat, rehabilitate orameliorate an individual's medical condition,including mental illness, or its effects, in orderto attain or maintain the individual's achievablehealth and independent functioning providedsuch services are: (1) Consistent withgenerally-accepted standards of medicalpractice that are defined as standards that arebased on (A) credible scientific evidencepublished in peer-reviewed medical literaturethat is generally recognized by the relevant14

medical community, (B) recommendations of aphysician-specialty society, (C) the views of physicianspracticing in relevant clinical areas, and (D) any otherrelevant factors; (2) clinically appropriate in terms oftype, frequency, timing, site, extent and duration andconsidered effective for the individual's illness, injuryor disease; (3) not primarily for the convenience of theindividual, the individual's health care provider orother health care providers; (4) not more costly thanan alternative service or sequence of services at leastas likely to produce equivalent therapeutic ordiagnostic results as to the diagnosis or treatment ofthe individual's illness, injury or disease; and (5)based on an assessment of the individual and his orher medical conditionLogistiCare is responsible for responding to clientrequests in a timely manner, appropriately evaluatingthe request, and for ensuring timely and appropriatetransportation to medically necessary services foreligible clients.They are responsible for obtaining documentation ofmedical necessity from a Physician or Physician’sAssistant (PA), Nurse Practitioner (PN), Clinical NurseSpecialist (CNS), or Registered Nurse (RN) that atteststhat they have personal knowledge of the client’scondition at the time transport is ordered. Thecertifying individual must be employed by the client'sattending physician or by the hospital or facility wherethe beneficiary is being treated and from which thebeneficiary is being transported to or from.In all cases, LogistiCare must keep the medicalnecessity documentation on file and present it to theDepartment upon request.15

Call Center Operation information: Toll free Reservation Phone Line - 24/7 toaccommodate Urgent Care & DischargeTransports (1-888-248-9895)Regular business hours Monday through Friday7 am to 6 pmDedicated Where’s My Ride Phone Line (800592-4291)Dedicated Facility Phone Line (888-866-3287)LogistiCare’s Online m/ctmember/enus/faq.aspxFrom here, you may access the Frequently AskedQuestions (FAQ) and the forms.Member Information BrochuresClosest Provider Certification form (CPC)Physician Transportation Restriction Form (PTR)Gas Reimbursement GuidelinesGas Reimbursement FormCompanion Referral Form (CRF)Parental Consent to Travel FormCovered Non-Covered Service List.16

The Member Services Web Portal is available 24hours a day/7 days a week at:https://member.logisticare.comTo use the Member Services Website you must: Have an e-mail account Have scheduled at least one reservation byphone. The LogistiCare staff can then registeryou to use the Online Member Services Website. Receive your ID so that you will be able to finishsetting up your account online.*The portal works with most common webbrowsers.From the Member Services Web Portal home page amember can: Review Alerts** Make and manage their TransportationReservations Manage their, My Profile, including membersassociated with the account Access the Help option** Alerts: When a member clicks the Alertsoption a snapshot of the current trips and the status(i.e. Pending, Denied, Requires More Information, andScheduled) for each trip for the member associatedwith the account. It also provides notifications,system maintenance, and system updates. To close theAlerts page, click the Close button on the lower right ofthe screen.17

FACILITY SERVICES WEBSITE �s online Facility Services Web portal isavailable to providers serving the CT Medicaidpopulation and can provide significant benefits forhealthcare providers such as: More reliable estimated time of arrival Fewer no-shows and cancelled appointments Pre-assigned return trips to reduce patientwaiting Specialized toll free access for healthcarefacilities Dedicated service representatives for casemananers and discharge planners Case management support State specificweb site for form download and programinformation Can make member reservations online Access Formsat: ,under the Downloads section of thewebsite for members that visit theirprovider more than three (3) times perweek at the same time. Notify LogistiCare to cancel a ride if amember’s discharge is canceled orrescheduled. Online reservations can be18

canceled online (at least 24 hours in advance);otherwise the facility representative may call 1 888866-3287Cancellations need to be made at least 24 hours inadvance.Facilities would still have the option to call the FacilityReservation Line at 1-866-866-3287, to make themembers reservations.Facilities interested in using the FSW should contactLogistiCare to set up an account.FORMSForms are updated as needed so they are not includedwith this brochure.Physician Transportation Restriction FormHusky A, C, and D Mileage Reimbursement FormsClosest Provider Certification FormRequest for Reimbursement of Medical Transportationby Personal CarCompanion Referral Form (CRF)Parental Consent to Travel Form19

gisticare.comLogistiCare Phone NumbersMembers:Request a ride Cancel /Reschedule/ UrgentRides/Form Status/Mass Transit/Gasreimbursement:888-248-9895“Where’s my ride?” 800-592-4291Complaints: 888-2489895 Facilities:Facility Assistance: 888-866-3287Hospital Discharges: 866-529-1946Complaints: 888-866-328720

Glossary of TermsAdministrative Hearing - This is where you challengethe decision for a denial of service. You are allowed tohave your request for transportation denial reviewed.CPC – Closest Provider Certificate- A form that isrequired for treatment at a healthcare provider that ismore than fifteen (15) miles from the members’residenceCompanion Referral Form (CRF): The necessary formthat documents medical/mental/intellectual/physicalneed of a traveling companion.N.O.A.- Notice of Action- A letter informing you thatyour request has been changed or denied.PTR- Physician Transportation Restriction Form- Aform stating your medical condition(s) that makes itnecessary for a specific type of service other than MassTransit.Standing Order- Scheduled to the same place on thesame day and time for up to two (2) months.21

ANDDecember 201622

Non-Emergency Medical Transportation (NEMT) is a limited transportation benefit that is provided to Medicaid members (Husky A, C, D and limited benefit . should be requested at least 5 business days before you need it to allow for delivery of tickets/ passes/ tokens. For other types of transportation, the request