Medical Transportation Program


1 General Information

The Medical Transportation Program (MTP), under the direction of the Texas Health and Human Services Commission (HHSC), arranges transportation and travel-related services for eligible Medicaid, Children with Special Health Care Needs (CSHCN) Services Program, and Transportation for Indigent Cancer Patients (TICP) clients who have no other means of transportation. MTP is responsible for the prior authorization of all MTP services.

MTP provides for the following general services:

Mass transit (intercity and intracity): Passes or tickets for client transport within a city and from city to city. Air travel is also an allowable service.

Demand response transportation: Common carriers such as taxi, wheelchair van, and other trans­portation according to contractual requirements.

Mileage reimbursement for enrolled individual transportation provider (ITP): The enrolled ITP can be the responsible party, family member, friend, neighbor, or client.

Meals: Contracted vendors (e.g., hospital cafeteria).

Lodging: Contracted hotels and motels.

Advanced funds: Financial services contractor.

Attendant: Responsible party, parent/guardian, etc., who accompanies the client to a health-care service.

Under the contract between Texas Medicaid & Healthcare Partnership (TMHP) and MTP, TMHP is responsible for enrollment of providers and processing of MTP provider claims.

MTP contracts with various provider types to arrange transportation and travel-related services for eligible MTP clients and their attendants.

There are three MTP provider types that enroll directly with TMHP:


Lodging providers

Meal providers

All other transportation providers arrange enrollment through MTP (e.g., transportation service area providers, client services providers).

1.1* Contacting MTP

If health-care providers have MTP-eligible clients who express difficulty accessing health-care services, advise the clients or their advocates to call the statewide MTP toll-free number at 1-877-633-8747 to request transportation services. MTP clients in the Houston/Beaumont area can call 1-855-687-4786 to request services. Clients in the Dallas/Ft. Worth area can call 1-855-687-3255 to request services. For transportation services within the county where the client lives, clients or their advocates must call the MTP office at least 2 business days before the scheduled appointment. For clients who need to travel beyond the county where they live, clients or their advocates must call the MTP office at least 5 business days before the scheduled appointment.

The client must provide the following information to the intake operator at the time of the call:

Client name, address, and, if available, the telephone number

Medicaid, TICP or CSHCN Services Program client identification number (if applicable) or Social Security number, and date of birth

Name, address, and telephone number of health-care provider and/or referring health-care provider

Purpose and date of trip and time of appointment

Affirmation that other means of transportation are unavailable

Special needs, including wheelchair lift or attendant(s)

Medical necessity verified by the Health Care Provider’s Statement of Need, if applicable

Affirmation that advance funds are needed in order for the recipient to access health-care services

Note:Clients must reimburse the department for any advance funds, and any portion thereof, that are not used for the specific prior authorized service.

2 Individual Transportation Provider (ITP)

ITPs are individuals who volunteer to use their personal vehicle to drive themselves, a friend, or a family member safely to the doctor, dentist, or drug store.

2.1Enrollment for ITPs

ITPs must follow all rules for enrollment that other providers follow when enrolling with TMHP.

To initiate the enrollment process, the MTP client must contact MTP to request a ride from an individual who is a potential ITP. This request is the first step in the enrollment process for the ITP.

After the client’s call, MTP sends the potential ITP’s information to TMHP, and TMHP mails the potential ITP an enrollment package. The ITP must fill out the Individual Transportation Provider Enrollment Application and mail it to TMHP with all requested documentation.

The provider must identify the MTP clients they will be transporting and whether they are related to the client. The application packet also includes an Electronic Funds Transfer (EFT) Agreement form that authorizes TMHP to deposit payments directly into a bank account, which results in faster payments.

After the ITP application has been processed, the ITP will receive a letter from TMHP that includes the Atypical Provider Identifier (API) and the Texas Provider Identifier (TPI) to be used when the ITP submits claim forms for mileage reimbursement.

2.2Prior Authorization for ITPs

Once an ITP is enrolled with TMHP and a client calls MTP to request a ride, MTP will mail a preprinted ITP Service Record (Form H3017) to the MTP client. The H3017 is the form the provider must mail to TMHP to be reimbursed for the ride.

Important:Only claims that are authorized by MTP will be considered for payment. All claims must be prior authorized to be paid.

Refer to:  Subsection 5, “Prior Authorization” in this handbook.

2.3Claims Filing for ITPs

To file a claim, an ITP completes the H3017 form that was sent to the Medicaid client and mails is to TMHP at the following address:

Texas Medicaid & Healthcare Partnership
PO Box 200555
Austin, TX 78720-0555

The H3017 includes the following transportation details:

Date of the ride

Number of miles authorized

Prior authorization number

MTP client’s name

ITP’s name.

The H3017 claim form must be signed by the doctor, dentist, or drug store representative that rendered services to the MTP client. This signature stands as proof that the ride authorized by MTP was taken. The ITP must also sign the claim form and include the API and TPI that was assigned to them by TMHP. If any of this required information is missing, the claim will be denied.

The provider must mail the completed claim form to TMHP after the client’s authorized ride, but no later than 95 days from the date of the ride. Any claims received by TMHP more than 95 days after the date of the ride will be denied.

An ITP may not charge an MTP client a fee for completing claim forms. TMHP also cannot be charged for the filing of claim forms.

3 Lodging Provider

Lodging providers are businesses that have entered into an enrollment contract to provide hotel/lodging facilities for MTP clients’ attendant(s) when authorized by MTP.

3.1Enrollment for Lodging Providers

Lodging providers must be enrolled with TMHP as an MTP provider to receive reimbursement for claims.

Lodging providers enroll in MTP in one of two ways:

Providers can download and fill out a paper Lodging Provider Enrollment Application and mail it to TMHP.

Providers can complete the enrollment process through the Provider Enrollment on the Portal (PEP) application on the TMHP website at

The provider must complete and return the entire provider enrollment application including the Lodging Provider Rate Information Sheet and the Internal Revenue Service (IRS) W-9 Tax Identifi­cation form. The enrollment packet contains an EFT form that authorizes direct deposit payments for faster reimbursement; however, completion of the EFT form is not a requirement for enrollment.

Lodging providers can download an application for MTP by visiting the MTP Lodging page on the TMHP website at

3.2Prior Authorization for Lodging Providers

An MTP client must contact MTP to request a lodging stay to initiate the claims process for lodging providers.

When MTP authorizes a request from the client for a lodging stay, the lodging provider will be sent the approved authorization and information including the client’s name and the date of stay. Each approved authorization is for one overnight stay and will have a unique authorization number.

Each overnight stay must be authorized by MTP, and a separate claim form must be submitted to TMHP for each individual overnight stay. It is the lodging provider’s responsibility to obtain the MTP client’s signature on each authorization form before it is submitted to TMHP.

Refer to:  Subsection 5, “Prior Authorization” in this handbook.

3.3Claims Filing for Lodging Providers

There are two ways for lodging providers to submit claims to TMHP, including:

By paper using the CMS-1500 paper claim form.

Refer to:  Subsection 6.6, “Paper Claims” in this handbook.

Electronically, using TMHP electronic data interchange (EDI) or the TexMedConnect functionality through the TMHP website.

Refer to:  Subsection 6.5, “Electronic Claims” in this handbook.

Lodging providers may not charge an MTP client a fee for completing claim forms. TMHP also cannot be charged for the filing of claim forms.

4 Meals Provider

4.1Enrollment for Meals Providers

Meal providers can enroll with TMHP in one of two ways:

Download and fill out a paper Meal Provider Enrollment Application and mail it to TMHP.

Complete the enrollment process through the PEP application on the TMHP website at

Meals providers can download an application for MTP by visiting the MTP Meals page on the TMHP website at

The provider must complete and return the IRS W-9 Tax Identification Form as part of the enrollment process. The enrollment packet contains an EFT form that authorizes direct deposit payments for faster reimbursement; however, completion of the EFT form is not a requirement for enrollment.

4.2Prior Authorization for Meals Providers

An MTP client must contact MTP to request meal services to initiate the claims process for meal providers.

Upon authorization of meal services, MTP will send an authorization form directly to the MTP client. This form will include the MTP client’s name, the attendant’s name, and the date of the authorized meal(s). The MTP client’s attendant must present this authorization form to the meal provider for meals to be received by the client.

Important:Only claims for authorized meal services are considered for payment.

One authorization covers all authorized meals for a single day. Each day of meals must be authorized by MTP and will be assigned a unique authorization number.

Refer to:  Subsection 5, “Prior Authorization” in this handbook.

4.3Claims Filing for Meals Providers

Providers must submit a separate claim form to TMHP for each unique authorization number (or day of meals).

There are two ways for providers to submit claims to TMHP:

By paper using the CMS-1500 paper claim form.

Refer to:  Subsection 6.6, “Paper Claims” in this handbook.

Electronically, using TMHP electronic data interchange (EDI) or the TexMedConnect functionality through the TMHP website.

Refer to:  Subsection 6.5, “Electronic Claims” in this handbook.

Meals providers may not charge an MTP client a fee for completing claim forms. TMHP also cannot be charged for the filing of claim forms.

5 Prior Authorization

All MTP services must be prior authorized by MTP, which issues all prior authorizations for transpor­tation services. The eligible MTP client must contact MTP to obtain an authorization. Claims that are submitted without proper prior authorization will be denied.

5.1Retention of Prior Authorization Documents

MTP prior authorization documents relating to Medicaid services or benefits provided to clients who are 20 years of age and younger must not be destroyed until the provider receives notice from HHSC. Examples of such documents include but are not limited to:

Correspondence with HHSC/MTP;



Contacts with clients who are class members

5.2Definition of Prior Authorization Documents

The term “prior authorization document” is broad and includes, but is not limited to, the following:

Paper records

Electronic files in any format

Database entries

The original and any drafts or non-identical copies of any document

Exhibits or attachments to documents

Handwritten documents


Drawings, graphs, charts

Electronic or videotape recordings

Computer disks

Other forms of computer memory storage

5.3Copies of Prior Authorization Documents

Providers are not required to retain multiple exact copies of a document. For example:

An exact electronic copy (e.g., scanned computer image, microfiche) may be retained instead of a paper copy.

If the last in a chain of emails is retained, it is not necessary to retain each of the individual emails included in the chain, as long as the email that is retained reflects all of the earlier emails.

However, a document containing any substantive editorial comment, margin notes, underlining, etc., is not an exact copy and becomes a new original that must be retained.

5.4Storage of Prior Authorization Document Storage

Relevant information and documents should be stored in a way that is protected from unintentional disclosure or destruction.

6 Claims Filing

This section contains instructions for completion of Medicaid-required claim forms. When filing a claim, providers should review the instructions carefully and complete all requested information. A correctly completed claim form is processed faster.

Texas Medicaid cannot make payments to clients, so the provider who performs the service must file an assigned claim. Federal regulations prohibit providers from charging clients a fee for completing or filing Medicaid claim forms. Providers are not allowed to charge TMHP for filing claims. The cost of claims filing is part of the usual and customary rate for doing business. Providers cannot bill Texas Medicaid or Medicaid clients for missed appointments or failure to keep an appointment. Only claims for services rendered are considered for payment.

Medicaid providers are also required to complete and sign authorized medical transportation forms (e.g., Form 3103, Individual Driver Registrant (IDR) Service Record, or Form 3111, Verification of Travel to Healthcare Services by Mass Transit) or provide an equivalent (e.g., provider statement on official letterhead) to attest that services were provided to a client on a specific date. The client presents these forms to the provider.

Providers are not allowed to bill clients or Texas Medicaid for completing these forms.

Medicaid claims are subject to the following procedures:

TMHP verifies all required information is present.

Claims filed under the same provider identifier and program and ready for disposition at the end of each week are paid to the provider with an explanation of each payment or denial. The explanation is called the Remittance and Status (R&S) Report, which may be received as a downloadable portable document format (PDF) version or on paper. A Health Insurance Portability and Accountability Act (HIPAA)-compliant 835 transaction file is also available for those providers who wish to import claim dispositions into a financial system.

An R&S Report is generated for providers that have weekly claim or financial activity with or without payment. The report identifies pending, paid, denied, and adjusted claims. If no claim activity or outstanding account receivables exist during the time period, an R&S Report is not generated for the week.

Providers can participate in the most efficient and effective method of submitting claims to TMHP by submitting claims through the TMHP Electronic Data Interchange (EDI) claims processing system using TexMedConnect or a third party vendor. Claims must contain the provider’s complete name, address, and provider identifier to avoid unnecessary delays in processing and payment.

6.1Claims Filing Deadlines

All claims for services rendered to eligible MTP clients are subject to a filing deadline from the DOS of:

95 days for in-state providers

365 days for out-of-state providers

Claims submitted by newly-enrolled MTP providers must be received within 95 days of the date the atypical provider identifier (API) is issued, and within 365 days of the date of service (DOS). Providers with a pending application should submit any claims that are nearing the 365-day deadline from the DOS. TMHP will reject all claims until an API is issued. MTP providers can use the TMHP rejection report or Return to Provider (RTP) letters as proof of meeting the 365- day deadline and submit an appeal.

6.2Auditing of Claims

Reimbursement may be recouped when the medical record does not document that the level of service provided accurately matches the level of service claimed. Furthermore, the level of service provided and documented must be medically necessary based on the clinical situation and needs of the patient.

HHSC and TMHP routinely perform retrospective reviews of all providers. HHSC ultimately is respon­sible for Texas Medicaid utilization review activities. This review includes comparing services billed to the client’s clinical record. The following requirements are general requirements for all providers. Any mandatory requirement not present in the client’s medical record subjects the associated services to recoupment.

6.3Important Codes for All MTP Providers

MTP providers must use the following codes when submitting claims:

Benefit Code = MTP

Provider Type = MT

Diagnosis Code = Z753

Place of Service = 09 for paper claims, 99 for TexMedConnect claims

Type of Service = 9

The following table shows additional codes that TMHP recommends for filing MTP claims. The codes are based on transportation provider type:

MTP Provider Description

Provider Specialty

Taxonomy Code

Recom­mended Procedure Code

Modifier Codes

Client Financial Services (CFS)





Individual Transpor­tation Provider (ITP)










Single occupancy


One-bedroom suite




King bedroom rate


Double occupancy room


Two bedroom suite


Additional person charge




Lodging taxes






Transportation Service Area Provider (TSAP)







Out of county


Reduced rate in-county


Reduced rate out of county

6.4Delegation of Signature Authority

A provider that delegate signatory authority to a member of the office staff or to a billing service remains responsible for the accuracy of all information on a claim submitted for payment. A provider’s employees or a billing service and its employees are equally responsible for any false billings in which they partici­pated or directed.

If the claim is prepared by a billing service or printed by data processing equipment, it is permissible to print “Signature on File” in place of the provider’s signature. When claims are prepared by a billing service, the billing service must obtain and keep a letter on file that is signed by the provider authorizing claim submission.

6.5Electronic Claims

6.5.1TMHP Electronic Data Interchange (EDI)

Providers are encouraged to submit claims using electronic methods. Providers can participate in the most efficient and effective method of submitting requests to TMHP by submitting through the TMHP EDI Gateway. TMHP uses the HIPAA-compliant American National Standards Institute (ANSI) ASC X12 4010A1 file format through secure socket layer (SSL) and virtual private networking (VPN) connec­tions for maximum security. Providers can access TMHP’s electronic services through the TMHP website at, TexMedConnect, vendor software, and billing agents. Providers may also submit claims using paper forms. Version 2001 0805 3 MTP Claim Filing.


TexMedConnect is a free, web-based, claims submission application provided by TMHP. Technical support and training for TexMedConnect are also available free from TMHP. Providers can submit claims, eligibility requests, claim status inquiries, appeals, and download ER&S Reports (in either PDF or ANSI 835 formats) using TexMedConnect. TexMedConnect can interactively submit individual claims that are processed in seconds. To use TexMedConnect, providers must have:

An internet service provider (ISP)

Microsoft Internet Explorer®

Google Chrome®

Mozilla Firefox®

A broadband connection is recommended but not required. Providers that use TexMedConnect can find the online instruction manual on the home page and on the EDI page of the TMHP website at

6.5.3Vendor Software

Providers that do not use TexMedConnect may use vendor software to create, submit, and retrieve data files. Providers can use software from any vendor listed on the EDI Submitter List, which is located on the EDI Vendor Testing web page of the TMHP website at There are hundreds of software vendors that have a wide assortment of services and that have been approved to submit electronic files to TMHP. Providers that plan to access TMHP’s electronic services with vendor software should contact the vendor for details on software requirements. TMHP does not make vendor recom­mendations or provide any assistance for vendor software. Not all vendor software offers the same features or levels of support. Providers are encouraged to research their software thoroughly to make certain that it meets their needs and that it has completed testing with TMHP.

Providers must setup their software or billing agent services to access the TMHP EDI Gateway. Providers who use billing agents or software vendors should contact those organizations for information on installation, settings, maintenance, and their processes and procedures for exchanging electronic data.

Providers that download the ANSI 835 file through TexMedConnect and providers that use vendor software must request a submitter ID. A submitter ID is necessary for vendor software to access TMHP’s electronic services. It serves as an electronic mailbox for the provider and TMHP to exchange data files. To order a submitter ID, providers must call the EDI Help Desk at 1-888-863-3638. Providers that use a billing agent do not need a submitter ID.

Providers may receive an ER&S Report by completing the Electronic Remittance and Status (ER&S) Agreement and submitting it to the EDI Help Desk after setting up access to the TMHP EDI Gateway. 4 Version 2001 0805 MTP Claim Filing.

6.5.4Third Party Vendor Implementation

TMHP requires all software vendors and billing agents to complete EDI testing before access to the production server is allowed. Vendors that wish to begin testing may either call the EDI Help Desk at 1-888-863-3638 or visit the EDIFECS testing site at and use the TMHP Support link. An EDIFECS account will be created for the vendor to begin testing EDI formats once they have enrolled for testing. After the successful completion of EDIFECS testing and the submission of a Trading Partner Agreement, vendors must then complete end-to-end testing on the TMHP test server. Software vendors and billing agents must be partnered with at least one Texas provider before a test submitter ID can be issued. When end-to-end testing has been completed, the software vendor or billing agent will be added to the EDI Submitter List. Providers and billing agents may then order production submitter IDs for use with the vendor’s software. Companion guides and vendor specifications are available in the EDI section of the TMHP website at

6.6Paper Claims

MTP providers can also file claims using the CMS-1500 paper claim form. Providers obtain copies of the CMS-1500 paper claim form from a vendor of their choice; TMHP does not supply them.

Providers must submit paper claims to TMHP at the following address:

Texas Medicaid & Healthcare Partnership
PO Box 200555
Austin, TX 78720-0555

6.6.1Tips on Expediting Paper Claims

Use the following guidelines to enhance the accuracy and timeliness of paper claims processing. requirements

Use original claim forms. Don’t use copies of claim forms.

Detach claims at perforated lines before mailing.

Use 10 x 13 inch envelopes to mail claims. Don’t fold claim forms, appeals, or correspondence.

Don’t use labels, stickers, or stamps on the claim form.

Don’t send duplicate copies of information.

Use 8 ½ x 11 inch paper. Don’t use paper smaller or larger than 8 ½ x 11 inches.

Don’t mail claims with correspondence for other departments. Version 2001 0805 5 MTP Claim Filing Fields

Print claim data within defined boxes on the claim form.

Use black ink, but not a black marker. Don’t use red ink or highlighters.

Use all capital letters.

Print using 10-pitch (12-point) Courier font, 10 point. Don’t use fonts smaller or larger than 12 points. Don’t use proportional fonts, such as Arial or Times Roman.

Use a laser printer for best results. Don’t use a dot matrix printer, if possible.

Don’t use dashes or slashes in date fields.

Use paper clips on claims or appeals if they include attachments. Don’t use glue, tape, or staples.

Place the claim form on top when sending new claims, followed by any medical records or other attachments.

Number the pages when sending when sending attachments or multiple claims for the same client (e.g., 1 of 2, 2 of 2).

Don’t total the billed amount on each claim form when submitting multi-page claims for the same client.

Note:It is strongly recommended that providers who submit paper claims keep a copy of the documentation they send.

All paper claims must be submitted with a TPI and NPI.

Modifiers describe and qualify the services provided by Texas Medicaid. A modifier is placed after the five-digit procedure code. to Claims

To expedite claims processing, providers must supply all information on the claim form itself and limit attachments to those required by TMHP or necessary to supply information to properly adjudicate the claim.

6.6.2CMS-1500 Instruction Table

The table below describes what information must be entered in each of the block numbers of the CMS-1500 claim form. Providers obtain copies of the CMS-1500 paper claim form from a vendor of their choice; TMHP does not supply them.

Block numbers not referenced in the table may be left blank. They are not required for TMHP to process MTP claims.

CMS 1500 - Required MTP Information


Block No




Insured’s ID No. (for program checked above, include all letters)

Enter the patient’s MPCN (10-digit) patient number from the MTP authorization form.


Patient’s name

Enter the patients last name, first name, and middle initial as printed on the MTP authorization form.

If the insured uses a last name suffix (e.g., Jr, Sr) enter it after the last name and before the first name.


Diagnosis or nature of illness or injury

The ICD-10-CM diagnosis codes recommended for MTP claims are Z753.


Prior authorization number

Enter the Prior Authorization Number issued by MTP.


Date(s) of service

Enter the date of service for each MTP authorization provided in a MM/ DD/YYYY format.


Place of service

The recommended POS code for MTP paper claims is 09. For electronic filing using TexMedConnect, the POS code is 99.


Fully describe procedures, medical services, or supplies furnished for each date given

“The recommended procedure code for TSAP claims is A0100 The recommended procedure code for CFS claims is A0170“


Diagnosis pointer

The recommended diagnosis codes are Z753 for all MTP claims.



Indicate the charges for the service listed


Days or units

Enter the number of services performed (such as the quantity billed) per MTP.


Accept assignment


All providers of the Texas Medicaid must accept assignment to receive payment by checking Yes.


Total charge

Enter the total charges.


Signature of physician or supplier

An authorized representative must sign and date the claim.

Billing services may print “Signature on File” in place of the provider’s signature if the billing service obtains and retains on file a letter signed by the provider authorizing this practice.


Billing provider info & PH #

Enter the billing provider’s name, street, city, state, ZIP+4 code, and telephone number.



Enter your API


Other ID #

Enter your TPI number

7 Claim Form Examples

The following linked claim form examples can also be found on the Claim Form Examples page of the Provider section of the TMHP website at

Claim Form Examples

Lodging Provider Paper Claim Form Example

Meals Provider Paper Claim Form Example