The AHCCCS Daily Trip Report: Signatures, Odometer Readings, and Errors That Deny Claims

What the Daily Trip Report is and when AHCCCS needs it

AHCCCS, Arizona’s Medicaid program, wants its own trip record with every fee-for-service NEMT claim. Chapter 14 of the AHCCCS Fee-For-Service Provider Billing Manual (revised July 31, 2026) says any non-emergency transportation claim sent without the AHCCCS Daily Trip Report, Exhibit 14-1, will be denied. Only that version counts. You may not build your own form, even one with the same boxes.

Fee-for-service members are the ones AHCCCS pays for directly, such as the 93,867 members of the American Indian Health Program in September 2026. Members of an AHCCCS health plan ride through the plan’s transportation vendor, and the plan’s manual sets the paperwork.

Arizona Complete Health’s provider manual (last updated September 1, 2026) tells transportation providers to follow chapter 14 and send a Daily Trip Report with the claim. The same section says an electronic claim with the pickup and drop-off locations filled in needs no trip ticket, while every paper claim needs one, and it wants the addresses in box 32, not field 19. If you drive plan members for a broker such as MTM Health in Arizona, get its rule in writing.

The report protects you after payment too. AHCCCS runs retrospective audits of ground NEMT providers to confirm mileage, wait time, diagnosis, and medical necessity, and you must hand over the records any time after the date of service. Trip records with missing information are subject to audit error and recoupment. For rates, enrollment, and prior authorization, see the Arizona guide.

How to fill out the Daily Trip Report, field by field

The form is two pages, with three trip sections on each page, numbered 1st through 6th. The instructions in Exhibit 14-2 (dated July 23, 2026) cover every box. Fill it in with a pen, in blue or black ink, and print clearly. Illegible reports can lead to audit error and recoupment.

The top: your company, the driver, and the vehicle

• Provider box, upper left. Your company’s name, AHCCCS provider ID, address, and phone number. A stamp is fine here.
• Driver’s name. The printed first and last name of the driver who gave the ride.
• Date. The date of service as mm/dd/yy or mm/dd/ccyy.
• Vehicle identification. The state where the vehicle is licensed, the plate or fleet number, and the make and color.
• Vehicle type. Check the box that fits. If none does, check Other and write in the type.

One report covers one member for one day. If more than one vehicle or driver carries that member that day, use a separate page for each vehicle, note it in Additional Information, and number every page at the bottom right. Together the pages make one report.

The member

Write the member’s AHCCCS ID, full name, date of birth as mm/dd/ccyy, and mailing address. Copy the ID exactly: it is a capital A followed by eight digits, and the same ID links your upload to the claim.

Each trip leg

Every leg from a pickup to a drop-off gets its own section:

1. Pickup and drop-off locations. The full street address, city, state, and ZIP code. Where there is no street address, use coordinates. If you cannot find coordinates, give the address or coordinates of a nearby landmark and the mileage from it. AHCCCS says a missing street address is never a reason to leave the location blank.
2. Clock times. Pickup and drop-off times with a.m. or p.m., such as 7:12 AM, and circle a.m. or p.m. on the form.
3. Odometer readings. The actual reading at pickup and at drop-off. Trip miles are the drop-off reading minus the pickup reading.
4. Type of trip. Round trip, one way, or multiple stops. For a round trip, use the 1st section for the ride there and the 2nd section for the ride back.
5. Reason for visit and diagnosis. Only as much as the member is willing to share. When you first arrange a ride, you must get enough information to know it goes to an AHCCCS-covered service, and AHCCCS says asking for it is not a HIPAA violation.
6. Escort. The escort’s first and last name and relationship to the member. See escorts and caregivers.

Exhibit 14-2 gives an example. A member rides from home to a doctor’s office, then to a pharmacy at another address, then home. That is three trips on one report, each with its own addresses, times, and odometer readings.

The bottom of page two

• Shared ride questions. Say whether other AHCCCS members rode in the vehicle, and whether any of them had a different pickup or drop-off. Answer yes if even one did, because it can affect the odometer readings.
• Additional Information. Anything AHCCCS needs to process the claim: a second vehicle, a detour, or why the miles home differ from the miles there.
• Member signature or fingerprint. See the next section.
• Driver signature. The driver prints a full name and the date on page one, then signs and dates page two. Initials, a symbol, a stamp, or any similar stand-in do not count, and the driver dates every page. AHCCCS added this wording to chapter 14 on July 31, 2026, to match the instructions.

Just above the driver’s signature, the form certifies that the information is true, accurate, and complete. It warns that false claims, statements, or documents may be prosecuted under federal or state law. Make sure every driver knows that before the first shift.

Who signs for the member

A member 18 or older signs for themselves, and so does an emancipated minor who shows proof of emancipation. When the member cannot sign, check the box that says so and use the right stand-in:

Situation	Who signs the member line
The member can sign	The member, in ink or by finger or pen on a tablet
The member cannot sign but can give a fingerprint	The member’s fingerprint, in the box on page two
The member cannot sign or fingerprint, and a parent, guardian, caretaker, escort, or family member is there	That person, with the member’s name and a note such as “by J Smith, daughter”
The member cannot sign or fingerprint and rode alone	The medical provider at the appointment
The member is a minor who is not emancipated	The legal guardian

The driver never signs for the member. That holds even when the driver is the member’s relative, caregiver, or physical or behavioral health care provider. On a tablet, a typed name never counts for the member or the driver.

Paper, tablet, or PDF: how to send the report

On paper. Mail the report with a paper CMS 1500 to AHCCCS Claims, P.O. Box 6270, Phoenix, AZ 85005, the address in chapter 4 (revised November 3, 2025). Use the standard red and white CMS 1500, because AHCCCS returns downloaded or printed copies of the claim form. AHCCCS images the claim and every page sent with it. Correction fluid and correction tape are not allowed, and AHCCCS warns that highlighter, color marks, and dark copy edges do not read on its imaging system.

On a tablet. You may fill in the AHCCCS form electronically if you protect member information under HIPAA and the AHCCCS Security Rule Compliance Summary Checklist, Attachment A to ACOM Policy 108 (policy effective September 26, 2025). The checklist walks through HIPAA Security Rule safeguards such as a risk analysis, a unique login for each user, automatic logoff, and controls on devices and media. See HIPAA for NEMT.

An electronic report goes in one of two ways: print it and mail it, or upload it as a PDF. AHCCCS will not accept HTML or Excel files of the report. It offers an Excel version so you can expand the Additional Information area, but you must convert it to PDF before sending. The PDF must let AHCCCS extract the document, or AHCCCS cannot view it.

How to upload the report to an electronic claim

AHCCCS’s NEMT Trip Report and Documentation Upload Guide (updated September 3, 2025) sets these steps:

1. Submit the claim first. Either put a paperwork (PWK) attachment number on the claim or use the 12-digit AHCCCS claim number. AHCCCS suggests building the PWK number from the member ID and the date of service, such as A12345678090525, with no slashes.
2. Open the upload form. In the EDI Solutions portal, go to Claim Attachments and choose Upload Attachment.
3. Use the same provider number as the claim. Enter the NPI if the claim used the NPI, or the 6-digit AHCCCS ID if it used that. Mixing them breaks the link.
4. Type the member ID with a capital A. A lowercase a keeps the documents from linking.
5. Upload one file. Combine every page into a single PDF.
6. Answer a denial with the claim reference number. If the claim is denied for missing information, upload again using the claim reference number, without line numbers such as 001, even if the first upload used a PWK number.

Billing companies and clearinghouses may become 275 trading partners and send the report as a HIPAA 275 attachment instead. See submitting NEMT claims electronically.

If you replace a denied or paid claim, send the report again. Chapter 4 says each claim must stand on its own, because the system cannot pull documents from an earlier version. See corrected NEMT claims.

How the claim has to match the report

AHCCCS reads the claim and the report together, so they have to tell the same story:

• One claim per member per date of service. Line 1 is the number of trips, line 2 the total loaded miles, and line 3 any wait time. Any further lines deny.
• No split billing. A claim with only the base code and a second claim with only the mileage both deny, and a second claim for the same member and date denies as a duplicate.
• Addresses on the claim itself. Since November 1, 2022, every NEMT claim lists pickup and drop-off addresses. On a paper CMS 1500, field 19 holds the street address and ZIP code only, as in “P- 1234 E Berry St 85000, D- 678 N Town St 85222”. On an 837P, the claim note in loop 2300 carries the full address, as in “P-123 Main St Phoenix AZ 85051 D-456 Uptown St Phoenix AZ 83034” (companion guide version 4.0, November 2022).
• Shared rides. Each member gets a separate report and claim with the miles of that member’s most direct route, and wait time is paid for one member only. See NEMT multiloading.
• Unknown diagnosis. AHCCCS accepts R68.89 for physical health and F99 for behavioral health on NEMT claims. See NEMT diagnosis codes.
• Six months to file. AHCCCS must receive the first claim within 6 months of the date of service (chapter 4). See timely filing limits.

The CMS 1500 guide covers the rest of the claim form.

Errors that deny or cut claims

Each of these comes from chapter 4, chapter 14, or the upload guide:

1. No Daily Trip Report, or a homemade one. The claim is denied.
2. A typed name in a signature line. It never counts, on paper or on a tablet.
3. The driver signs for the member. Never allowed, even for a relative.
4. Initials, a symbol, or a stamp for the driver’s signature. The driver signs by hand.
5. Erasures or correction fluid. Draw one line through the error and print the correct information.
6. A blank location. Use coordinates, or a landmark and the mileage from it.
7. Miles home that differ from miles there, with no reason given. AHCCCS may cut the difference.
8. A pickup or drop-off away from home that adds miles, with no reason given. AHCCCS requires a reason for the extra miles.
9. One report for two riders. Every member on a shared ride needs a separate report.
10. Base rate and mileage on separate claims, or a second claim for the same member and day.
11. An Excel or HTML file, or a PDF AHCCCS cannot extract.
12. An upload that does not link, from the wrong kind of provider number, a lowercase a in the member ID, or line numbers after the claim reference number.
13. No addresses on the claim. The report alone is not enough.

For reading denial codes and fixing the claim, see NEMT claim denials.

A daily routine for drivers and billers

1. Start a fresh Exhibit 14-1 for each member each day, on paper or in the AHCCCS file on a tablet. Never retype the form.
2. Fill in the top before the first pickup: company, driver, date, vehicle, and member.
3. Write the leg at the curb. Address, clock time with a.m. or p.m., and odometer reading at every pickup and drop-off, before the van moves.
4. Get the signature before the member leaves, or the right stand-in from the table above.
5. Note anything unusual in Additional Information while it is fresh.
6. Close out at the end of the shift. The driver prints name and date on page one, signs and dates page two, dates every page, and numbers the pages.
7. Check it in the office. The biller recomputes trip miles from the odometer readings, compares the legs there and back, and matches the claim lines and addresses to the report.
8. Send it and keep it. Upload one PDF linked to the claim, and keep the original, because AHCCCS can ask for it any time after the date of service.

The trip log template works for your own records and for other payers, but AHCCCS fee-for-service claims need Exhibit 14-1 itself. For what other states and brokers ask of a trip record, see NEMT trip documentation.