Gas Reimbursement Program
Information for Traditional Medicaid

Enrollment Instructions

Through this guide, you’ll learn how to enroll as a transportation provider and begin requesting gas reimbursement for eligible trips. The instructions include both online and paper enrollment options, and cover everything from required forms and documentation to how to schedule rides and submit completed trip forms.

• Step-by-step instructions to enroll in the Medicaid Gas Reimbursement Program

• Verida’s scheduling process and contact information

• What forms are required and how to submit reimbursement claims

• Resources and support contacts if you need help at any point

⭐ REQUIRED:

Family Member or Associate Transportation Services Form
The member confirms the need for frequent medical trips, identifies a Medicaid member, and specifies the enrolling driver (a form must be submitted for each of your drivers) 

Fill in the: Medicaid Member Transportation Request Form

For instructions on applying to be a DRIVER please see use one of the options below.

⭐ OPTION 1: 

Online Provider Enrollment Application
For instructions on applying by mail, please see below

To begin the application process, follow these steps:

1. • 1. Navigate to the IHCP Website to begin the process

     2. Select, “Provider Enrollment Application” on the left and then Continue

     3. For Provider Classification select, “Billing”

     4. For Provider Type select, “26: Transportation”

     5. Enrollment Request Type, “New Enrollment”

     6. Are you a disregarded entity? NO

     7. Toggle, TIN Type to “SSN” enter your social security number.

     8. Enter the rest of the information and continue to the next section.

     9. For Specialty “266: Family Member” and click “Add”

     10. Provider Addresses 

It is required to specify all three addresses:

1. • 10. • • Driver's Permanent Address

           • Pay-To Address

           • Mail-To Address

↪ Find your your 4-digit zip code extension search here

⭐ Helpful Tip: Use the copy function to quickly replicate duplicate addresses. 

1. • 11. Provider Identification 

Enter your information for the following fields:

1. • 11. • • • Driver’s license information

             • Auto insurance Information

             • Vehicle Registration Information

     12. EFT Information 

Enter your information for the following fields:

1. • 12. • • • Routing Information

             • Account Information

     13. Other Information:

Enter your information for the following fields:

1. • 13. • • • Medicaid Member Name

             • Medicaid Member ID

     14. Complete the other questions and sections to continue to submit your application.

     15. To complete the process, upload all 4 required documents:

☑ Copy of a Valid Driver License 

☑ Current Auto insurance 

☑ Current Vehicle Registration

☑ Current version of the W-9 form from the Internal Revenue Service (IRS)

↪ Go to the www.irs.gov website and locate the W-9 form and download the form. 

⭐ OPTION 2: 

Paper Provider Enrollment Application:

For instructions on applying online, please see above.

To begin the application process, follow these steps:

1. Download, Print, and Complete the Medicaid Transportation Provider Application Packet

⭐ Note: Make sure to include the "Electronic Funds Transfer Addendum/Maintenance Form" 

↪ Located on page 11 of the application.

2. Gather Driver’s Documentation to Submit:

The driver must include copies of the following documents with their application:

☑ Valid Driver License

☑ Current Auto insurance

☑ Current Vehicle Registration

☑ Current version of the W-9 form from the Internal Revenue Service (IRS)

↪ Go to the www.irs.gov website and locate the W-9 form and download the form. 

3. Obtain the Medicaid Member Transportation Request Form, completed by the Medicaid member, and include it with your submission.