Wisconsin In-Network Transportation Provider Checklist

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including hospital discharges, Provider shall accept reservations and jobnumbers from LGTC by telephone.ix) Provider shall transport Participants, adult escorts, transportationattendants, or personal assistants as applicable and in accordance with thespecifications of the reservations provided by LGTC and the terms of thisAgreement. Provider, upon consultation with LGTC, may refuse totransport any person who, in the judgment of the Provider, is a threat tothe health, safety, or welfare of either Provider’s employees or otherParticipants, or prevents or inhibits the vehicle from being operated in asafe manner.x) Provider shall reroute trip assignment at least 24-hours prior to thescheduled pick-up time to allow LGTC to make alternative arrangements.This requirement only applies to trip reservations that have beensubmitted to Provider at least 36 hours prior to the scheduled pick-uptime. In the event that Provider does not provide 24-hours notice andLGTC must make, as a result of the short notice, premium price alternatetransportation arrangements, Provider will be responsible for anyadditional charges incurred by LGTC. These charges may be deductedfrom amounts owed to Provider. This provision does not apply tocircumstances beyond the control of Provider (e.g., sudden vehiclebreakdown or vehicle accident).xi) Provider will ensure that all information obtained regarding Participantsin connection with this Agreement is held in strict confidence and is usedonly as required in the performance of Provider’s obligations. (For furtherconfidentiality requirements, see Exhibit C – Business AssociateAgreement.)xii) Provider shall promptly inform LGTC if a Participant is assigned to animproper level of service (i.e., ambulatory patient assigned to awheelchair trip, or wheelchair bound patient assigned to an ambulatorytrip).xiii) Client staff or its agent may ride on trips to monitor service. Providershall make all vehicles available to Client or it agents for inspection atany time.b) Pick Up and Delivery Standards. Provider shall provide transportation servicesthat comply with the following minimum service standards. LGTC’s or Client’sstaff, or their official agent, may ride on trips with the Participant to monitorservice.i) On time performance of scheduled pick-ups shall be the standard practice.“On time” means at the scheduled pick up time or up to fifteen minutesafter that time. In addition, early arrival of the vehicle is permissible solong as no Participant is required to board the vehicle before thescheduled pick-up time. Arrival more than fifteen minutes after thescheduled A-Leg pick-up time, or more than thirty minutes after theWisconsin NET ProgramVersion: March 25 2011Page 4
ii)iii)iv)scheduled B-Leg pick up time is considered a “late pick-up”. Themonthly average wait time for all A-Leg pick-ups performed by Providermay not exceed 15 minutes after the scheduled pick-up time and theactual wait time for any specific pick-up may not exceed 30 minutes afterthe scheduled pick-up time. The monthly average wait time for all B-Leg pick-ups performed by Provider may not exceed thirty (30) minutesafter the scheduled pick-up time and actual wait time for any specificpick-up may not exceed 45 minutes after the scheduled pick-up time.However, Provider must ensure that the average wait time for B-Legpick-up of dialysis patients does not does fifteen (15) minutes.The driver shall make his presence known to the Participant upon arrivalat the pick-up address and must wait at least ten (10) minutes after thescheduled pick-up time before the Participant may be considered a “noshow”. If the Participant is not present for pick up, the driver shall notifyProvider’s dispatcher before leaving the pick-up location and documentthe attempted pick-up on the daily trip log.Provider shall deliver the Participant to scheduled medical appointmentswithin fifteen (15) minutes of the medical appointment time as standardpractice, however, an earlier drop off before the appointment time may beacceptable in unusual situations on a case-by-case basis. However, in noevent shall a Participant be dropped off for a medical appointment morethan thirty (30) minutes before the scheduled appointment time, unlessthis is done at the client’s request. Provider shall ensure that Participantsare picked up at prearranged times for the return trip if the medicalservice provider follows a regular schedule. Provider will monitor returntrips to ensure Participants are delivered to their return destination intimely manner. The prearranged times may not be changed by Provider orthe driver without prior permission from LGTC. Based on input fromhealthcare facilities, LGTC reserves the right, in its sole discretion, tomeasure on-time performance of Provider by reference to the on-timedelivery of Participants to scheduled medical appointments.For “will call” return pick-up reservations from a medical appointment,the Provider shall arrive within one (1) hour after the time Provider isnotified that the Participant is ready, or by the close of the business dayfor the medical service provider, whichever is earlier.v) If a delay of fifteen (15) minutes or more occurs in the course of pickingup scheduled riders, Provider must contact waiting Participants at theirpick-up points to inform them of the delay and the expected arrival timeof the vehicle. Provider must advise scheduled riders of alternate pick-uparrangements when appropriate.vi)vii)If a delay occurs that will result in a Participant being late for a medicalappointment, Provider must contact LGTC who will notify the medicalprovider of the late arrival.For same day hospital discharge reservations, Provider shall pick-upWisconsin NET ProgramVersion: March 25 2011Page 5
Page 1 and 2: Please return all documents to:1275
Page 3 and 4: TRANSPORTATION AGREEMENT(the “Agr
Page 5: Provider may be withdrawn by LGTC,
Page 9 and 10: utilized by Provider.ii) The number
Page 11 and 12: • ADA regulations;• Client Cont
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
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AFTER HOURS CONTACTINFORMATION SHEE
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Form W-9 (Rev. 1-2003) Page 2Exampl
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Form W-9 (Rev. 1-2003) Page 4Part I
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Dear LogistiCare Transportation Pro
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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
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X. THIRD PARTY WEBSITESThe Software
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(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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