Form DSS-NEMT-950 "Non-emergency Medical Travel (Nemt) Reimbursement Form" - South Dakota

What Is Form DSS-NEMT-950?

This is a legal form that was released by the South Dakota Department of Social Services - a government authority operating within South Dakota. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 1, 2021;
  • The latest edition provided by the South Dakota Department of Social Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DSS-NEMT-950 by clicking the link below or browse more documents and templates provided by the South Dakota Department of Social Services.

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Download Form DSS-NEMT-950 "Non-emergency Medical Travel (Nemt) Reimbursement Form" - South Dakota

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SOUTH DAKOTA MEDICAID
DSS-NEMT-950 04/21
NON-EMERGENCY MEDICAL TRAVEL (NEMT) REIMBURSEMENT FORM
- To Be Returned After Your Trip -
-See reverse side for program guidelines, form instructions and contact/mailing information-
***TO BE FILLED OUT BY RECIPIENT, PARENT OR GUARDIAN***
SECTION 1: MEDICAID RECIPIENT INFORMATION
(If there are additional family members that traveled and had a medical appointment, please list them on a separate sheet of paper and attach to this form.)
Name:
Date of Birth:
Medicaid #:
Address:
Phone #:
SECTION 2: PAYMENT INFORMATION
Payment Goes To:
Phone #:
Mailing Address:
Have you completed a NEMT Payment Authorization form?
Yes. Your reimbursement will be deposited after your claim has been processed. Please allow 6-8 weeks for processing.
No. Before reimbursement can be made, you MUST complete and return a NEMT Payment Authorization Form along with any
required documentation. NEMT Payment Authorization Forms can be found at any local DSS Office, online at
https://dss.sd.gov/medicaid/recipients/title19transportation.aspx
or by calling 1-866-403-1433.
SECTION 3: FINANCIAL ASSISTANCE
(If you received financial assistance from more than one organization, please list them on a separate sheet of paper and attach to this form.)
Did you receive financial assistance from another source for this medical trip?
YES
NO
* **Examples include (but are not limited to): Check/Money, Gas Vouchers, Meal Passes, Lodging Assistance
Name of Organization:
Phone #:
Mailing Address:
Type of Assistance:
Check/Money
Gas Voucher
Meal Passes
Lodging
Other
Amount of Assistance:
SECTION 4: TRIP INFORMATION
From (City):
To (City):
Departure Date:
Return Date:
Shriner’s Van
Mode of Transportation:
Personal Vehicle
Hospital Transportation Service
____________________
__________________
Transportation provider in my community
Other
Lodging Information:
Recipient Lodging:
Driver/Escort Lodging:
Motel (receipt required)
Motel (receipt required)
Family/Friend (no receipt required)
Family/Friend (no receipt required)
Inpatient Hospital Stay (no receipt required)
Stayed in hospital (no receipt required)
Other _______________________________
Other _______________________________
SECTION 5: SIGNATURE
I understand that I will be paid mileage only to the closest provider capable of providing the necessary services. I certify that the
above information is correct to the best of my knowledge and any attached receipts represent eligible expenses. I understand that
there are penalties for fraudulently submitting claims for reimbursement and misrepresentation of receipts submitted for payment.
______________________________________________
________________________
SIGNATURE:
DATE:
(Recipient, parent, or guardian)
SECTION 6: MEDICAL PROVIDER SECTION
***TO BE FILLED OUT BY THE MEDICAL PROVIDER***
Name of Medical Facility:
Address:
Phone #:
Name of Doctor (first/last):
Service NPI:
Type of Provider (GP, Cardiologist, Dentist, Etc.):
Purpose of Visit (MUST be specific):
Is this a Medicaid covered service?
Yes
No
Is there a referral from the PCP for closest specialty services on file?
YES
NO
Was the patient hospitalized?
Yes
No
If yes, list admit/discharge dates/times:
Appointment Date:
Appointment Time:
______________________________________________
________________________
SIGNATURE:
DATE:
(Receptionist, Nurse, or Doctor Signature)
SOUTH DAKOTA MEDICAID
DSS-NEMT-950 04/21
NON-EMERGENCY MEDICAL TRAVEL (NEMT) REIMBURSEMENT FORM
- To Be Returned After Your Trip -
-See reverse side for program guidelines, form instructions and contact/mailing information-
***TO BE FILLED OUT BY RECIPIENT, PARENT OR GUARDIAN***
SECTION 1: MEDICAID RECIPIENT INFORMATION
(If there are additional family members that traveled and had a medical appointment, please list them on a separate sheet of paper and attach to this form.)
Name:
Date of Birth:
Medicaid #:
Address:
Phone #:
SECTION 2: PAYMENT INFORMATION
Payment Goes To:
Phone #:
Mailing Address:
Have you completed a NEMT Payment Authorization form?
Yes. Your reimbursement will be deposited after your claim has been processed. Please allow 6-8 weeks for processing.
No. Before reimbursement can be made, you MUST complete and return a NEMT Payment Authorization Form along with any
required documentation. NEMT Payment Authorization Forms can be found at any local DSS Office, online at
https://dss.sd.gov/medicaid/recipients/title19transportation.aspx
or by calling 1-866-403-1433.
SECTION 3: FINANCIAL ASSISTANCE
(If you received financial assistance from more than one organization, please list them on a separate sheet of paper and attach to this form.)
Did you receive financial assistance from another source for this medical trip?
YES
NO
* **Examples include (but are not limited to): Check/Money, Gas Vouchers, Meal Passes, Lodging Assistance
Name of Organization:
Phone #:
Mailing Address:
Type of Assistance:
Check/Money
Gas Voucher
Meal Passes
Lodging
Other
Amount of Assistance:
SECTION 4: TRIP INFORMATION
From (City):
To (City):
Departure Date:
Return Date:
Shriner’s Van
Mode of Transportation:
Personal Vehicle
Hospital Transportation Service
____________________
__________________
Transportation provider in my community
Other
Lodging Information:
Recipient Lodging:
Driver/Escort Lodging:
Motel (receipt required)
Motel (receipt required)
Family/Friend (no receipt required)
Family/Friend (no receipt required)
Inpatient Hospital Stay (no receipt required)
Stayed in hospital (no receipt required)
Other _______________________________
Other _______________________________
SECTION 5: SIGNATURE
I understand that I will be paid mileage only to the closest provider capable of providing the necessary services. I certify that the
above information is correct to the best of my knowledge and any attached receipts represent eligible expenses. I understand that
there are penalties for fraudulently submitting claims for reimbursement and misrepresentation of receipts submitted for payment.
______________________________________________
________________________
SIGNATURE:
DATE:
(Recipient, parent, or guardian)
SECTION 6: MEDICAL PROVIDER SECTION
***TO BE FILLED OUT BY THE MEDICAL PROVIDER***
Name of Medical Facility:
Address:
Phone #:
Name of Doctor (first/last):
Service NPI:
Type of Provider (GP, Cardiologist, Dentist, Etc.):
Purpose of Visit (MUST be specific):
Is this a Medicaid covered service?
Yes
No
Is there a referral from the PCP for closest specialty services on file?
YES
NO
Was the patient hospitalized?
Yes
No
If yes, list admit/discharge dates/times:
Appointment Date:
Appointment Time:
______________________________________________
________________________
SIGNATURE:
DATE:
(Receptionist, Nurse, or Doctor Signature)
INSTRUCTIONS:
SECTION 1: MEDICAID RECIPIENT INFORMATION
This section contains information regarding the Medicaid recipient or person(s) who had the medical appointment. If additional
individuals traveled and had a medical appointment please attach a separate sheet of paper and include the name, date of birth
and Medicaid ID number.
SECTION 2: PAYMENT INFORMATION
This section contains the name of the person who reimbursement should be sent to. If assistance was received from another
source to help with the medical trip, reimbursement will be sent to the organization first and any remaining balance will be
reimbursed to the individual listed in this section.
SECTION 3: FINANCIAL ASSISTANCE
If you checked “YES”, you must complete this section. If you received assistance from multiple organizations, please attach a
separate sheet of paper and include the organizations name, address, phone number, type of assistance and amount of
assistance provided.
SECTION 4: TRIP INFORMATION
This section must be completed by the recipient, parent or guardian. A separate Medicaid NEMT form must be completed for each
medical trip.
-
From (City) - city from which you departed
-
To (City) - city you are traveling to
-
Departure Date - date you left your city of residence
-
Return Date - date you returned to your city of residence
-
Mode of Transportation: how you were transported to your medical appointment
-
Lodging: lodging information for the recipient and escort (if medically necessary)
*Motel receipts are required. The receipt must display the nightly rate and verification of payment.
*Fuel and meal receipts are not required.
SECTION 5: SIGNATURE
The form must be signed and dated by the recipient, parent or guardian.
SECTION 6: MEDICAL PROVIDER SECTION
This section MUST be completed and signed by the medical provider. If the recipient has multiple appointments with different
doctors, please attach appointment verification and a purpose of visit for each appointment from the medical facility.
MAIL/FAX:
Please make sure that all sections of this form are complete before returning to our office. Incomplete forms may delay the
processing of your claim. Please return this form, along with any necessary documentation, referrals or receipts to:
Department of Social Services
Local Phone Number: (605) 773-6527
Finance/EBT
Toll Free Number: 866-403-1433
700 Governor’s Drive
Fax Number: (605) 773-8461
Pierre, SD 57501
Email: dss.ebtstateoffice@state.sd.us
PROGRAM GUIDELINES:
You must be on a medical assistance program that provides Medicaid NEMT coverage at the time of service.
Transportation must be to the closest medical facility or medical provider capable of providing the necessary services.
The service must be a Medicaid covered service provided by a medical provider who is enrolled in the medical assistance program.
Travel to a medical specialist other than a primary care provider requires a referral card.
(This does not apply for children in the custody of Child Protection Services.)
A Medicaid NEMT Reimbursement Form must be completed and submitted for each medical trip.
Mileage will be reimbursed according to established program guidelines.
Mileage is limited to the actual miles between two cities and does not include miles driven within the city.
Lodging is reimbursable when the provider is at least 150 miles from the recipient's city of residence and travel is to obtain specialty care or
.
treatment that results in an overnight stay
Meals will be reimbursed only if an overnight stay is medically necessary and the overnight meets the lodging requirement criteria.
Recipient only: During an inpatient hospital stay meals and lodging will not be reimbursed.
The Medicaid NEMT program must receive a completed claim form within six months following the month the service was provided.
The Department of Social Services reserves the right to deny coverage for any requests made outside the general coverage guidelines of
these rules.
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