Wisconsin In-Network Transportation Provider Checklist

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sterile eyewash.xviii) All vehicles shall be equipped with three (3) portable triangular reflectorsmounted on stands. Use of flares is prohibited and may not be carried onboard.xix) All vehicles shall carry extra electrical fuses.xx)xxi)xxii)All vehicles shall carry a functioning flashlight and an ice scraper.All vehicles shall be equipped with a “spill kit” that includes liquid spillabsorbent, latex or other impermeable gloves, hazardous waste disposalbags, scrub brush, disinfectant and deodorizer.All vehicles shall contain a current map of the applicable geographic areawith sufficient detail to locate Participant and medical provider addresses.xxiii) All vehicles shall be equipped with a working fire extinguisher that shallbe stored in a safe location.xxiv) Provider shall utilize only its own leased or owned vehicles and shall notsublet, subcontract or arrange for transportation under this Agreementfrom any third party.xxv)All vehicles must be equipped with a two-way communications systemlinking each vehicle with the Provider’s primary place of business. Cellphones are acceptable, but pagers are not acceptable substitutes. Avehicle with an inoperative two-way communication system shall beplaced out of service until the system is repaired or replaced.xxvi) All vehicles must properly utilize approved child safety seats whentransporting children in accordance with Wisconsin laws and regulations.xxvii) All vehicles shall have a functioning interior light within the passengercompartment.xxviii) All vehicles shall have adequate sidewall padding and the vehicle’s floormust be covered with commercial anti-skid flooring or carpeting. Flooringor carpeting in vehicles equipped to transport wheelchair passengers shallnot interfere with wheelchair movement between the lift and thewheelchair positions.xxix)xxx)All vehicles designed to accommodate more than six (6) passengers shallbe equipped with a retractable step, fixed sideboard (running board), or astep stool approved by LGTC to aid Participant boarding. This step shallbe capable of safely supporting 300 lbs and shall be no more than 12inches above ground level. The step shall have a nonskid top surface noless than eight inches by twelve inches. Removable steps shall beproperly secured while the vehicle is in motion. Under no circumstanceswill a milk crate or similar substitute be accepted as a substitute for a stepstool.Any vehicle found deficient with any State or Federal regulation or in thefollowing areas must be immediately removed from service:• Wisconsin Department of Health Services Specialized MedicalVehicle licensing and equipment/restraint device requirements;• Department of Motor Vehicles licensing requirements, safetystandards, annual Motor Bus/Human Service Vehicle Inspections;Wisconsin NET ProgramVersion: March 25 2011Page 8
• ADA regulations;• Client Contract requirements;• Vehicles currently placed out of service by the Wisconsin State Patrol;• If the overall condition of the vehicle creates a health or safety hazardfor the vehicle occupants;• Any vehicle receiving two (2) or more legitimized complaints frompassengers concerning cleanliness, temperature deficiencies, or otherdeficiencies within a five (5) day period must be removed from serviceuntil vehicle is inspected by LGTC and appropriate corrective actionstaken. Such actions must be documented and become a part of thevehicle's permanent record; or• Any vehicle found not in compliance with the vehicle standardscreated under the Client Contract or any state or federal standards(until verified for correction of deficiencies).d) Wheelchair Vehicle Requirements. All vehicles used to transport wheelchairpassengers (“Wheelchair Vehicle”) must meet the General Vehicle Requirementsset forth above as well as the following additional requirements.i) Each Wheelchair Vehicle must maintain a floor-to-ceiling heightclearance in the passenger compartment of at least fifty-six (56) inches(applicable to lift vehicles only, and not to ramp vehicles).ii) Each Wheelchair Vehicle must have an engine-wheelchair lift interlocksystem that requires the Wheelchair Vehicle’s transmission to be in parkand the emergency brake engaged to prevent vehicle movement when thelift is deployed.iii) All wheelchair ramps used on vehicles shall be certified as capable ofregularly servicing a six hundred pounds (600 lbs) load.iv) Each Wheelchair Vehicle with a hydraulic or electromechanical poweredwheelchair lift must have the lift mounted so not to impair the structuralintegrity of the vehicle. The lift must meet the following specifications:a) is capable of elevating and lowering a 600-pound load without theouter edge of the lift sagging, or tilting downwards more than oneinch, nor shall the platform deflection be more than three (3)degrees under a 600-pound load;b) the lift platform most be at least thirty (30) inches wide and fortyeight(48) inches long;c) the lift platform shall not have a gap between the platform surfaceand the roll-off barrier greater than 5/8 of an inch. When raised,the gap between the platform and the vehicle floor shall notexceed 1/2 inch horizontally and 5/8 inch vertically;d) the lift controls shall be accessible and operable from inside oroutside the vehicle, and shall be secure from accidental orunauthorized operation;e) the lift shall be powered from the vehicle’s electrical system. Thelift platform shall be able to be raised/lowered manually withWisconsin NET ProgramVersion: March 25 2011Page 9
Page 1 and 2: Please return all documents to:1275
Page 3 and 4: TRANSPORTATION AGREEMENT(the “Agr
Page 5 and 6: Provider may be withdrawn by LGTC,
Page 7 and 8: ii)iii)iv)scheduled B-Leg pick up t
Page 9: utilized by Provider.ii) The number
Page 13 and 14: vi)type of vehicle in which it is i
Page 15 and 16: and satisfactorily cleared a nation
Page 17 and 18: ix)a Participant, or in the presenc
Page 19 and 20: iv)Provider warrants that it has no
Page 21 and 22: a) name, date of birth and social s
Page 23 and 24: from establishing or maintaining se
Page 25 and 26: the dispute shall be referred for b
Page 27 and 28: EXHIBIT ALIQUIDATED DAMAGESThe Part
Page 29 and 30: Requirement:Provider must perform t
Page 32 and 33: To determine the payment amount LGT
Page 34 and 35: Exhibit B - Execution PageLOGISTICA
Page 36 and 37: scope of the employment or other pr
Page 38 and 39: or created or received by BUSINESS
Page 40 and 41: presenting a preponderance of the e
Page 42 and 43: EXHIBIT EMedicare Advantage Program
Page 44 and 45: information and data necessary for:
Page 46 and 47: e reviewed and approved by Health P
Page 48 and 49: Non-Emergency Medical Transportatio
Page 50 and 51: LOGISTICARE INSURANCE CREDENTIALING
Page 52 and 53: Please describe your hours of opera
Page 54 and 55: Network Development503 Oak Place, S
Page 56 and 57: AFTER HOURS CONTACTINFORMATION SHEE
Page 58 and 59: Form W-9 (Rev. 1-2003) Page 2Exampl
Page 60 and 61:
Form W-9 (Rev. 1-2003) Page 4Part I
Page 62 and 63:
Dear LogistiCare Transportation Pro
Page 64 and 65:
Electronic Data Interchange (EDI) A
Page 66 and 67:
Date: __________________________Log
Page 68 and 69:
Software User AgreementWHEREAS, Log
Page 70 and 71:
III.OWNERSHIPThe Software is protec
Page 72 and 73:
X. THIRD PARTY WEBSITESThe Software
Page 74 and 75:
(B) The Content may not be copied,
Page 76 and 77:
this Agreement, or the infringement
Page 78 and 79:
LogistiCare Driver ListLegal name D
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Wisconsin In-Network Transportation Provider Checklist

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