Medicaid Transportation Justification Request
Form Template
In case of an emergency, there are various transportation services available.
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An enrollee in the Medicaid health plan can choose from the following transportation services when making a request for long term or temporary medical services: livery, ambulette ambulatory, ambulette wheelchair, stretcher van, BLS ambulance, and ALS ambulance. The Medicaid Transportation Justification Request app asks each enrollee to justify the mode of transportation and explain the medical necessity to obtain prior authorization. The enrollee will also clarify if medical care is long term or temporary within in the app. The Medicaid Transportation Justification Request app is easy to fill out and can be edited and saved.
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