Wisconsin In-Network Transportation Provider Checklist

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Dear LogistiCare Transportation Provider:LogistiCare Transportation ProviderElectronic Data Interchange (EDI) PacketLogistiCare has opened a secured web site designed to improve and streamline communicationbetween you and LogistiCare. Using the web site, you can print or download your trip list, enterinformation about trips that you complete for LogistiCare, reroute trips, and enter trips that werenot completed or were cancelled. You may also bill LogistiCare using this site, and if you chooseto do so, you can obtain certain performance reports on your drivers and vehicles. Please notethat certain billing functions are only available to fully contracted providers with rate and mileageagreements.Use of the site is strictly voluntary. To utilize the site, you must register with our web siteprovider, Provado Technologies, LLC. The attached Electronic Data Interchange (EDI) formsmust be filled out, signed and forwarded to Provado Technologies. The forms include:1. Transportation Provider EDI Operational Information Form – use this form toprovide your contact information to Provado Technologies and designate the peopleauthorized to sign User Requests.2. Electronic Data Interchange (EDI) Agreement – this form represents the agreementbetween you and LogistiCare Solutions, LLC regarding the use of the secured website.3. EDI User Form – use this form to add or remove individual users from the system.You are responsible for properly managing your employees’ access to the system.If you are interested in using the site, please print the forms and have them filled out and signedby an authorized individual at your company. If you are a brand new provider, includeoriginals of these documents with your contracts. If you are an existing provider, send theoriginals to Provado Technologies, LLC at the address indicated on the form. The originals ofthe first two forms must be sent. Copies will not be accepted. The EDI User form can be sentvia fax.Notes:Providers who work in multiple states but only have one billing / back office addressneed only sign the EDI Agreement form once but must submit multiple OperationalInformation sheets (one for each state).Providers who work in multiple states and have separate billing / back office addressesmust sign the EDI Agreement and Operational Information forms for each state.Page 60
LogistiCare Transportation ProviderEDI Operational InformationPlease Type or Print ClearlyCompany Name: _____________________________________________________________Mailing Address: ___________________________________________________________________________________________________________________________Contact Name: ______________________________________________________________Job Title:______________________________________________________________Phone Number: _______________________________Fax Number:_______________________________Email Address: ______________________________________________________________LogistiCare Provider Number (Shorthand): ____________________Contracted Provider? ⁯ Yes ⁯ NoAuthorized Signatures: The following authorized signatures will be accepted on User Requestforms. If the signature on the User Request form does not match one of the below signatures, therequest will be denied.__________________________ _____________________ _______________________Signature Title Name__________________________ _____________________ _______________________Signature Title Name__________________________ _____________________ _______________________Signature Title NameNew Providers include signed Originals with your contract documents.Existing Providers Mail Originals to:Provado Technologies, LLC.Attn: LogistiCare TP Services8647 Baypine RdSuite 204Jacksonville, FL 32256Page 61
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Please return all documents to:1275
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TRANSPORTATION AGREEMENT(the “Agr
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Provider may be withdrawn by LGTC,
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ii)iii)iv)scheduled B-Leg pick up t
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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
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 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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