ModivCare Mileage Reimbursement Trip Log: Filing, Deadlines, Denials

The Modivcare mileage reimbursement trip log is the form that pays you back for driving yourself, or having someone drive you, to a covered medical appointment under a Medicaid managed care plan. To get paid, you need a trip number for each appointment, a completed log with every field filled in, a signature from the provider you saw, and a submission that reaches Modivcare before your plan’s deadline. Miss any one of those and the claim is denied.

Get the Form and a Trip Number First

Two things have to happen before you write anything down: you need the log itself, and you need a trip number for every appointment.

Download the log from mymodivcare.com/mileage-reimbursement. The page has separate fillable PDFs for Florida, Texas, Cook County (Illinois), and a general version for all other states, each in English and Spanish.¹ Prefer paper? Call the Modivcare customer service number on the back of your health plan card and ask them to mail one.

When you call to schedule a ride, the reservation specialist gives you a trip number. Write it on the form right then. Forgetting the trip number is the most common reason reimbursements get denied.² Each appointment gets its own number, so three visits means three numbers to track.

What Goes in Each Field

At the top of the form, enter your name, member ID from your health plan card, and the driver’s name.³ Only one driver per form: if different people drive you on different days, use a separate log for each driver.²

Each row of the log covers one trip. The columns ask for:

Trip date, meaning the date of the medical appointment.
Trip number from the reservation specialist.
Total miles driven, calculated from your odometer or a mapping tool. Whether that is round-trip or one-way depends on how your plan’s form is structured.
Provider name, the doctor, clinic, or facility you visited.
Provider phone number.
Physician or clinician signature, left blank for the provider to complete at the appointment.

These are the standard column headings on the Modivcare log.⁴ Fill in every column except the signature space before you leave for the appointment.

Formatting Rules That Actually Matter

Modivcare scans these forms, so how the page looks matters. Their instructions say to use black or dark blue ink, print legibly with space between words, and skip special characters or symbols. Do not cross out mistakes, highlight anything, or write over the section headers. If you make an error, start fresh on a new form rather than correcting it in place.²

Get the Provider Signature at the Appointment

This is the step people forget, and it sinks more claims than anything else. Your doctor or clinician has to sign the row for that trip to confirm you were actually there.¹ No signature, no reimbursement.

Bring the log with you every time and hand it to the front desk or your provider before you leave. Chasing a signature days later, by phone or by mail, creates delays and some offices will not do it. Make it part of the visit: co-pay, signature, out the door.

How to Submit the Completed Form

Once every row has a signature and no field is blank, you have three ways to send it in.

The Modivcare Drive App

The Modivcare Drive app, on the App Store and Google Play, lets you file mileage claims from your phone without a paper log. Members who use the app together with the Modivcare Smart Card receive payments seven times faster than those who mail forms.⁵ The app also keeps your trip history so you are not reconstructing details weeks later.

Mail

Mail the completed, signed form to the claims address printed on your trip log or instruction letter. One commonly listed address is:

ModivCare Claims Department
Mileage Reimbursement
798 Park Ave NW
Norton, VA 24273⁶

Check the address on your own form, because it varies by state and health plan. Photocopy the signed log before you drop it in the mailbox. If the envelope disappears, you cannot recreate the original signatures. Certified mail or a tracking number is worth the small extra cost.

Fax

Fax the completed form to 1-800-486-7642.⁶ Keep the confirmation page as your proof of submission.

Submission Deadlines

Deadlines depend on your state and health plan, so read the instructions that came with your form. Some plans require the completed log within 30 days of the earliest appointment on it.² Others allow up to 95 days from the ride date.⁷ A late form gets denied even if every other detail is right, so submit soon after each appointment rather than waiting to fill the whole page.

Rates and How You Get Paid

The per-mile rate is not the same everywhere. It varies by state and health plan. One Florida plan reimburses at $0.54 per mile.⁶ Your log or welcome packet should list the applicable rate; if it does not, call customer service before submitting so you know what to expect.

The standard payment is a paper check. Modivcare states that once it receives your completed form, payment is mailed within 15 days.⁶ Add postal time on top of that.

The Modivcare Smart Card is a prepaid card that receives all your reimbursement payments instead of a check. You get an email or text when funds load, and every payment lands in one place.⁵ Paired with the Drive app, it is the fastest option.

To check where a claim stands, log in at mymodivcare.com to see pending, approved, or denied status. If a payment is late, call the customer service number on your health plan card for a specific claim lookup.

Why Claims Get Denied

Most denials come from a short list of preventable mistakes:

Missing trip number. The most common error. A blank trip number field triggers an automatic denial.²
No provider signature. An empty signature space means a rejected form.¹
Late submission. Past the plan’s deadline, the claim is denied even if everything else is correct.²
Illegible or damaged form. Smudged ink, cross-outs, abbreviations, or writing over section headers can trigger a denial or a manual review that delays payment.
Incomplete fields. Every field other than the signature space must be filled in before you submit.

Some members are not eligible for reimbursement at all. Under California’s Department of Health Care Services rules, Medi-Cal beneficiaries enrolled in a managed care organization who drive themselves to appointments cannot be reimbursed.² Confirm your plan’s rules before spending time on the paperwork.

If Your Claim Is Denied

A denial is not always the end. If the problem is a missing field or an illegible entry, you can often fix the form and resubmit inside the original deadline. Call customer service to find out exactly why it was denied and whether a corrected resubmission is accepted.

Because Modivcare operates under Medicaid managed care plans, you also have broader appeal rights. Federal rules give you 180 days from the date you receive a denial notice to file an internal appeal with your health plan. Include your name, claim number, and health insurance ID, along with a clear statement that you are appealing. A supporting letter from your doctor confirming the appointment strengthens the record.⁸ If the internal appeal fails, you can request an external review, typically within 60 days of the internal decision, where an independent reviewer examines the claim.

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Modivcare. Mileage Reimbursement
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Modivcare. Mileage Reimbursement Trip Log and Invoice Instructions
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Modivcare. Help and FAQs
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Modivcare. Mileage Reimbursement Trip Log
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Modivcare. Use the Modivcare Smart Card and App to Get Mileage Reimbursement
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Modivcare. Modivcare Mileage Reimbursement Trip Log
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Modivcare. Modivcare Individual Transportation Participant Enrollment Packet
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Centers for Medicare & Medicaid Services. Has Your Health Insurer Denied Payment for a Medical Service? You Have a Right to Appeal