Section He-W 574.06 - Submission of Claims(a) All drivers seeking reimbursement for general medical transportation services shall complete and submit a Form 13A, "Medicaid Transportation Reimbursement Form" (03/15) .(b) Form 13A shall be completed in the following manner:(1) The recipient shall obtain the medicaid enrolled provider's signature on the Form 13A at the time of the service provision, certifying the following: "I certify that NH Medicaid covered services were rendered for this recipient on the trip date indicated."; and(2) The recipient, or the recipient's parent or legal guardian, and the volunteer driver if applicable, shall sign and date the Form 13A prior to submitting the form to the department, as follows: a. If the driver is the recipient, the recipient shall sign and date the "Driver Signature" line;b. If the driver is a volunteer driver: 1.The recipient shall sign and date the "Recipient Signature" line; and
2.The volunteer driver shall sign the "Driver Signature" line; and
c. The individual(s) in a. and b. above shall certify the following: "This is to certify that the information above is true, accurate and complete. I understand that payment of this claim may be from Federal and State funds and that any false claims, statements, documents or the concealment of material fact may be prosecuted under applicable Federal and State Laws. ( 42 CFR 455.18 ) ".
(c) All drivers shall include copies of receipts for tolls, parking, and public transportation with the completed Form 13A, as applicable.(d) All completed Form 13A forms shall be submitted to the department within 90 calendar days of the date transportation services were provided or performed.(e) Submission of claims for multiple trips in one day shall be limited to the submission of one claim per trip regardless of the number of passengers. A driver shall not submit separate claims for each passenger.N.H. Admin. Code § He-W 574.06
(See Revision Note at chapter heading He-W 500); ss by #6163, eff 1-4-96, EXPIRED: 1-4-04
New. #8732, eff 9-30-06
Amended byVolume XXXV Number 18, Filed May 7, 2015 , Proposed by #10810, Effective 4/9/2015, Expires4/9/2025.