Forms.petersenhealthcare.net



MTM Trip Scheduling

(Includes Meridian, Harmony/Wellcare, Aetna and some Humana plans)

MUST BE DONE AT LEAST THREE BUSINESS DAYS AHEAD OF TIME

1. Complete a Petersen Trip Ticket before calling for a trip reservation. The MTM operator will ask for the following information so be sure to have it all written down:

a. Member’s name (resident)

b. Member’s date of birth

c. Member’s address (will be the facility name and address)

d. Member’s (facility’s) phone number

e. Member’s ID # (Medicaid number)

f. If in a wheelchair, combined weight of wheelchair and resident.

g. Provider’s name (the medical provider that they are seeing)

h. Provider’s address

i. Provider’s phone number

j. Time of the appointment (actual appointment time for verification)

k. Estimated return time (can be “left open” if unsure)

l. Facility’s fax number and DON’s name (for Level of Need forms)

2. Call one of these phone numbers and follow the prompts:

a. Meridian/MTM 1-844-299-6238

b. Harmony/Wellcare, Humana, Aetna 1-866-606-3700 (select Member not Provider)

3. Explain to the operator that this is a resident of a Petersen Health Care facility, that we are a Sole Source Provider and that the facility van needs to be selected for transportation. The PHC vendor code is C344 . Let the phone operator know right away that we are a sole source provider and to not set the trip as gas mileage reimbursement. They may just assume that we want gas mileage reimbursement so be sure to let them know not to set it that way. If there are problems, ask for a supervisor.

4. If the resident is wheelchair bound or needs an attendant, MTM will need to obtain a LON (Level of Need) form. This is the same as the state’s CTS form. The MTM operator will ask for the medical provider’s fax number for this form but, per MTM, give them the facility’s fax number and DON’s name instead

5. Ask for a trip number and write it down on the Petersen trip ticket

6. Have the driver complete an MTM Daily Driver’s Trip Log when transporting.

7. Send the MTM trip log and the Petersen trip ticket to Michelle Spears once completed.

MTM Daily Trip Log

o All drivers should have a MTM Daily Trip log to document any MTM managed trips. Here is a breakdown of how to complete the log

▪ Transportation Provider-Facility’s name Petersen Health Care / Facility

▪ Date of Service, Driver’s License Number, last five digits of Vehicle VIN are self-explanatory

▪ MTM Trip Number-provided at the time of scheduling. Suggested to use a PHC trip ticket when scheduling and write this number on it

▪ Recipient’s printed name-name of rider

▪ AM/PM of pick up- write AM or PM based on the time of pick-up

▪ Scheduled Pick-up time will be set when calling in the trip.

▪ Pickup Arrival-time when the pickup/loading begins. Should be the same as Schedule time

▪ Pickup Departure-time when the vehicle is ready to pull away

▪ Drop off time-time when the unloading takes place at the medical provider’s address

▪ Member’s Signature-signature of the resident. The driver can write “PUTS” (stands for patient unable to sign) if the rider cannot sign for themselves. Put a brief explanation on the log also (i.e. Dementia, tremors, blind, etc). It’s ok to use more than one line as long as no other trips are written on the line.

o Each “leg” of the trip has its own line. So, there will be a line for leaving the facility/home of a community rider and then a line for the return trip

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