LogistiCare New York Facility Network

	Title	Description
	Logisticare's Responsibilities in New York	Lists the types of transportation and geographical regions that LogistiCare is responsible for.
	New York Facility Brochure	Explains the processes used to request transportation through the LogistiCare Facilities department.
	Facility Key Telephone Numbers	The phone and fax numbers for reaching the LogistiCare Facilities department.
	Gas Reimbursement	Explains the criteria and how plan members are reimbursed.
	Gas Reimbursement Form	A form, which must be completed by a medical professional, when requesting transportation for a member that has access to a vehicle or can be transported by friend or relative.
	Mass Transit Department, MetroCard Request Form	A form used for a Mass Transit request.
	Mass Transit Department, MetroCard Hospital-Facility Reimbursement Form	A member reimbursement form which is utilized by Hospitals, Facilities, and programs who distribute MetroCards for reimbursement.
	MLTC - Single Trip Reservation Form	A form used to request a single trip for a plan member.
	Form W-9, Request for Taxpayer Identification Number and Certification	IRS Form W-9 is used by a person who files information returns with the IRS to report transactions.
	Standing Order Request Form	A form used to request recurring transportation for a member that goes to the same facility three or more times per week.
	Single Trip Form	A form used to request a single trip for a plan member.
	Physician’s Transportation Restriction Form	A form, which must be completed by a medical professional, when requesting transportation for a member that is not able to utilize public transportation.
	AmeriChoice Announcement to Facilities	Informs AmeriChoice providers that effective November 1, all non-emergency transportation services for members with transportation benefits must be pre-arranged through LogistiCare.
	AmeriChoice Announcement to Transportation Providers	Informs AmeriChoice transportation providers that effective November 1, LogistiCare will be arranging and providing all transportation for AmeriChoice members.
	WellCare of New York, Inc. Announcement to Facilities	Informs WellCare of New York Health Plan providers that effective December 1, 2010, non-emergency transportation services will be coordinated by LogistiCare.
	Affinity Announcement to Facilities	Informs Affinity Health Plan providers that effective November 1, all non-emergency transportation services for Medicaid, Medicare Advantage, and Medicaid Advantage members with transportation benefits must be pre-arranged through LogistiCare.
	Amerigroup Announcement to Facilities	Informs Amerigroup Health Plan of New York providers that effective November 1, all non-emergency transportation services for Medicaid, Medicare and MLTC members with transportation benefits must be pre-arranged through LogistiCare.
	Nassau County Medicaid Announcement to Facilities	Informs Nassau County Medicaid providers that effective January 1 2012, all non-emergency transportation services for members with transportation benefits must be pre-arranged through LogistiCare
	Nassau County Medicaid -Single Trip Form	A form used to request a single trip for a plan member.
	Nassau County Medicaid- Closest Provider Form	A Form to request the approval of medical transportation outside Nassau County’s Common Medical Marketing Area CMMA
	Nassau County Medicaid Facsimile Cover Sheet	A Form used by facilities when a fax is emailed to LogistiCare
	Nassau County Physician’s Transportation Restriction Form	A form, which must be completed by a medical professional, when requesting transportation for a member that requires transportation to and from a medical appointment
	Nassau County Medicaid -Standing Order Request Form	A form used to request recurring transportation for a member that goes to the same facility three or more times per week

New YorkFacility Network

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