Gas Reimbursment

• Transportation for the member needs to be scheduled at least two business days before the member’s healthcare appointment. This will help ensure the driver is eligible. Call 1-855-369-3723 (TTY: 711) to book an appointment. You may also schedule a ride using the MTM Link Member Portal or Mobile App. Click here to access MTM Link.
• The driver must fill out the Driver Registration form before the trip.
• The driver must live at a separate address from the member. Gas reimbursement will not be paid to drivers who live at the same address of the member.
• The member must be enrolled with Louisiana Healthcare Connections on the date of the trip.
• Only one fee per trip will be paid, regardless of the number of members transported.
• If a member gets a prescription from the health care provider, they should stop and pick it up on the way home from their appointment. This will be counted as one trip.
• A medical provider must verify that the member attended the scheduled appointment. The medical provider must sign/stamp and print their name on the Gas Reimbursement Form.
• The Gas Reimbursement Form must be fully completed, and all parking and toll receipts attached. The reimbursement form for trips occurring on or before September 30, 2023 can be found here on the Print Forms page. Forms that are missing information will be denied.

To sign up as a driver, the following information must be submitted using the Driver Registration form:

• Full name of driver
• Physical address of driver (must match the driver’s license and cannot be a PO Box)
• The driver’s contact information, including email and phone
• The social security number of the driver
• A list of the Louisiana Healthcare Connections members they are looking to drive (no more than 5)
• A copy of your current and valid driver’s license
• Vehicle information, including the VIN and license plate number
• A copy of your current and valid vehicle insurance card
• A copy of your vehicle registration
• The driver’s bank information for payment

No, the driver does not need to own the vehicle. But the driver does need to provide a copy of valid vehicle insurance and vehicle registration.

Please re-submit the Driver Registration Form to update a driver’s:

• Contact information
• Driver’s license
• Vehicle information
• Vehicle insurance
• Vehicle registration
• Banking information
• List of members they will be driving

The new information will be automatically updated on the driver’s profile.

Yes, each date of service must have a medical provider signature/stamp in order for reimbursement to be approved. Each trip will be confirmed with the provider’s office before payments will be made.

• The Driver Registration form can be sent in any time before the member books his or her trip. Trips need to be booked two business days before the member’s appointment. If the Driver Registration form has not been sent in at the time of the member’s appointment, an MTM representative will try to reach out to the driver to get the missing information.
• The Gas Reimbursement form needs to be filled out and returned to MTM within 365 days of your trip. Don’t forget to attach all parking and toll receipts.

The completed driver registration and gas reimbursement forms can be sent to MTM via email, fax, or mail. Don’t forget to include copies of the driver and vehicle documents. This must be done within 365 days of your trip. Forms can be submitted by:

• Email: payme@mtm-inc.net
• Fax: 1-855-667-2557
• Mail: MTM, Attn: Gas Reimbursement, 16 Hawk Ridge Dr., Lake Saint Louis, MO 63367

Approved trips will be paid out within these time frames:

• Electronic payments: 1-2 weeks.
• Payments via paper check: 4-6 weeks. Paper checks are mailed out on the last day of each month.