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Dhb 5048

DMA-5048-2026

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4.7 out of 5

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The document outlines the process for Medicaid beneficiaries to request transportation exceptions, including necessary identifying information, consent for information release, and justifications for exceptions such as distance to providers or special transportation needs. It includes sections for beneficiary details, requested exceptions, and provider attestations, emphasizing the importance of accurate completion to avoid delays.

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Click ‘Get Form’ to open the DMA-5048 in the editor.
Begin with Section 1, where you will enter identifying information. Fill in the County Department of Social Services, date, beneficiary name, address, date of birth, Medicaid ID, phone number, caseworker name, and caseworker phone.
Move to Section 2 for Medicaid Beneficiary Consent. Enter the beneficiary's name and authorize a medical provider to release necessary information by filling in their details. Ensure the signature and date are completed.
In Section 3, specify the exception requested and justification. Indicate if transportation is needed to a distant provider or if special accommodations are required. Provide detailed explanations as prompted.
Complete Section 4 by having the provider print their name, phone number, and sign with the date to attest that all statements are true.

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Versions	Form popularity	Fillable & printable
2022	4.6 Satisfied (22 Votes)
2018	4.7 Satisfied (41 Votes)
2015	4.8 Satisfied (56 Votes)

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What is non-emergency medical transportation?

Non-emergency patient transport services These services provide free transport to and from hospital for people including: those whose condition means they need additional medical support during their journey. those who find it difficult to walk. parents or guardians of children who are being transported.

Does NC Medicaid pay for transportation?

Medicaid is required to assure transportation to medical appointments for all eligible individuals who need and request assistance with transportation. Transportation will be available if the recipient receives a Medicaid covered service provided by a qualified Medicaid provider (enrolled as a NC Medicaid provider).

What is the phone number for NC Medicaid transportation?

ModivCare: Transportation provider shall submit a W-9, Account Setup Agreement, and the trip information (run sheet, driver log, etc.) to ModivCare securely at ncnetwork@modivcare.com or may request authorization by calling 855-397-3604.

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What is the number for Medicaid transportation in NC?

For information about your ride after you set it up, call Ride Assist at 855-397-3602. Use this number to activate a Will Call pickup, or if your transportation is late for a scheduled pickup. Use this number, too, if you need to make a change or cancel a previously scheduled reservation.

How much does Medicaid pay for non-emergency transportation in NC?

The NEMT reimbursement rate for Ambulance NEMT Services was increased from $78.25 to $474.00 with an effective date of Jan. 1, 2019. Upon implementation of the rate increase, claims processed with dates of service from Jan. 1, 2019 through the implementation date will be systematically reprocessed.

What does NC Medicaid cover?

NC Medicaid covers most health services. It includes doctor visits, check-ups, emergency care, hospital services, maternity and postpartum care, vision and hearing services, prescription drugs, behavioral health, preventive and wellness services, dental care, medical-related devices and more.

DMA-5048-2026

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