Trip Log Instructions – Pay Back for Paratransit Co-Pay

Are you certified to use paratransit service offered through the Americans with Disabilities Act (ADA)? If so, MTM can pay you back for your co-payment used for trips to your Medicaid-related healthcare visit.

If you want to be paid back, you must fill out and send us your Trip Log that shows all the facts about the trip. The log must be signed by your healthcare provider. Follow these steps:

  1. Set up a visit with your healthcare provider like a Medicaid doctor or dentist. This is your appointment.
  2. Call us before your appointment. Our toll-free number is 1-855-687-4786.
  3. Fill in the boxes on the Trip Log.
  4. When you call, we will give you a trip number. You will need to write the trip number on the Trip Log. There are sections for 12 different trips on the Trip Log.
  5. Take the Trip Log with you to your healthcare appointment. Ask someone from the provider’s office to sign where it says, “Signature and Title of Healthcare Provider.” That person can be a nurse, a therapist, or a doctor’s or dentist’s assistant. That person can also fill in the boxes for Healthcare Provider Phone, Name, and Address or you can fill those in yourself. You will also need to fill in the boxes showing your Appointment Date and Time, the Type of Trip, and Address where you were picked up.
  6. When you are ready to turn in your Trip Log for payment, sign it at the bottom and send it to us through the mail or by fax. The toll-free fax number is 1-888-513-1610. Our mailing address is: MTM Attention: Trip Logs 16 Hawk Ridge Drive Lake St. Louis, MO 63367

Remember:

  • Send us your finished Trip Log within 60 days of the first trip you write onto the form. You can send in the Trip Log if it shows only one trip or several.
  • A one-way trip is from your home to the appointment. A round trip is from your home to the appointment and then back home. If you have a trip with more stops, such as two appointments in the same trip, write each part of the trip as a separate trip. For example:
    • Trip#1–home to first doctor
    • Trip#2–first doctor to second doctor
    • Trip#3–second doctor to home
  • If you forgot to bring your Trip Log to your appointment, ask your healthcare provider for a note on their letterhead. The note should say you were seen by the healthcare provider and it should show the date of your appointment. When you’re ready to send in your Trip Log, attach the note from your provider in place of a signature.
  • Before you begin filling in the Trip Log, make copies of it while it’s blank. That way you have extra copies. If you ever need more copies, call us at 1-888-513-0703 (toll-free) and we’ll mail you one. Or, you can download this form at www.mtm-inc.net/texas.
  • Keep a copy of your completed Trip Log for your records.
  • We cannot accept Trip Logs that are missing information. Make sure each box of the form is filled in. We will send the Trip Log back to you if it is missing information.
  • Do you have questions about the Trip Log and how you use it to get paid back? Call us at 1-888-513-0703 (toll-free).