Wisconsin In-Network Transportation Provider Checklist

Requirement:Provider must perform transportation services with the class of service (ambulatory, wheelchair,stretcher or ambulance) requested by LGTC.Liquidated Damages:$200 per occurrence where a vehicle is utilized that is of a class of service lower than thatrequested.Requirement:Provider must pick up Medicaid Participants at the scheduled time.Liquidated Damages:$10 per occurrence where vehicle arrives more than 15 minutes after the scheduled pick-up time.This provision will be applied if more than 10% of scheduled pick-ups in any given month arelate pick-ups. This provision will not apply if the cause of the delay is beyond the control of theProvider.Requirement:Provider is required to assure that Participants are delivered to scheduled health careappointments on time.Liquidated Damages:$10 per occurrence where Participant is more than 15 minutes late to a scheduled appointment.This provision will be applied if more than 10% of scheduled drop-offs in any given month arelate drop-offs. This provision will not apply if the cause of the delay is beyond the control of theProvider.Requirement:Provider is required to assure that dialysis patients are delivered to their scheduled appointmentson time.Liquidated Damages:$100 for each instance in which arrival at a dialysis clinic for a scheduled dialysis appointment islate by more than 15 minutes. An additional fifty dollars per hour or portion thereof per instancewill be assessed for each late arrival that exceeds one hour, to a maximum of two hundred fiftydollars ($250) per trip. This provision will not apply if the cause of the delay is beyond thecontrol of the Provider.Requirement:Provider must provide termination notice within the terms of this Agreement.Liquidated Damages:Failure to provide termination notice in compliance with this Agreement will result in theforfeiture of all outstanding amounts due to Provider. Reroute of trips greater than a “dailyaverage of 10%” after termination notice is provided will be construed as failing to providesufficient notice. Provider and LGTC will mutually discuss if any unexpected circumstancebeyond the Provider’s control has occurred to warrant such reroutes.Wisconsin NET ProgramVersion: March 25 2011Page 27