# MTM Distance Verification Form in 2027: Getting Rides Approved to a Faraway Specialist

Canonical URL: https://nemtguide.com/guides/mtm-distance-verification-form/ · Updated 2026-10-06

An MTM distance verification form is a statement from the member's referring or treating provider explaining why the patient must travel past closer providers for care. MTM Health books no ride to a provider outside the member's area until it reviews the form. Send it at least two to five business days before the visit, depending on the state, marked one-time or ongoing with an end date.

- Medicaid generally pays for rides to the nearest qualified provider, so a farther one needs a written medical reason.
- The referring or treating provider signs the form, and MTM books nothing to that address until it reviews it.
- Send it two to five business days ahead (Connecticut takes up to 10 to process), and mark it ongoing with an end date for repeat visits.
- Where a state sets a mileage trigger, it ranges from 10 miles in non-rural Connecticut to 101 miles in Nevada.
- For your company, a missing form means the trip never reaches your queue, so check approval dates on long standing rides.

## Why MTM asks for a distance form

Medicaid generally pays for a ride to the nearest qualified provider, not to any provider the member picks. CMS says so in its Medicaid Transportation Coverage Guide (SMD 23-006, September 28, 2023), and also warns states not to hold to it too tightly: a denial can violate the member's freedom of choice when the ride costs about the same, when leaving the provider would harm the member, or when only that provider has the needed skills. The same guide tells states to set a usual distance and a review process for requests beyond it.

With MTM Health, the review is the distance verification form. MTM's standard form, posted on its healthcare providers page as of October 2026, says members must use the provider closest to home that can meet their medical needs, and it asks the member's doctor to say why the member cannot be treated closer.

The form protects the broker too. Nevada's Medicaid Services Manual (Chapter 1900, effective January 1, 2026) makes the broker verify that members use the nearest appropriate provider, and lets the state make the broker refund the monthly payment it received for any member who rode to a farther provider with no documented reason.

## What the form asks and who signs it

The member's referring or treating provider fills it out, not the member and not the transportation company. MTM's standard online form asks for:

- The member's name, date of birth, Medicaid number, and appointment date and time.
- The provider or facility the member is being sent to.
- Why the member cannot be treated by a provider closer to home.
- The specific diagnosis.
- Whether the approval is one-time or for ongoing treatment, and the end date if ongoing.
- Whether the signer is the referring or the rendering physician, with a signature, NPI, address, and date.

The form says to return it at least five business days before the appointment, and that MTM cannot arrange transportation to that address until it reviews and processes it. Wheelchair, stretcher, and other higher levels of service are a separate question, answered on the [Level of Need form](https://nemtguide.com/guides/mtm-level-of-need-form/). Some states fold both into one document, as Connecticut does.

## Where to send the form, by state

MTM posts its own version of the form in Connecticut, Idaho, Minnesota, Nevada, and Wisconsin, and links the standard online form in Rhode Island and Texas. The trigger and the address differ, as of October 2026:

| State | When it applies | Where it goes |
|---|---|---|
| Connecticut | Over 10 miles from home in non-rural areas, or 20 in rural areas | Fax 860-724-2159 or CM-Connecticut@mtm-inc.net |
| Idaho | A provider outside the member's covered service area | Fax 844-879-7347, MTM Utilization Management |
| Iowa | A provider past the closest one, unless under 10 miles farther or medically justified | No state form posted; ask CO-IA@mtm-inc.net |
| Minnesota | The closest provider able to treat; trips past 30 miles (primary care) or 60 (specialty) need authorization | Fax 651-203-1262 or mnetcaremanagement@mtm-inc.net |
| Missouri | A provider past the travel standard for its specialty and the member's county | No state form posted; a note from the doctor |
| Nevada | A provider outside the service area; trips of 101 miles or more may need one | Fax 1-877-406-0658 or CM-Nevada@mtm-inc.net, 5 business days ahead |
| Rhode Island and Texas | A provider outside the member's covered service area | MTM's standard online form, 5 business days ahead |
| Wisconsin | Care at a distant Wisconsin Medicaid provider | Fax 888-506-7708 or the online form, 2 business days ahead |

### Connecticut

The HUSKY Health benefits grid (last update September 11, 2023) says the transportation vendor arranges rides to the closest appropriate provider. MTM folds the distance check into its Medical Necessity Form. Part D, the Mileage Override Request, is required for trips over 10 miles in a non-rural area or 20 miles in a rural one, per MTM's instructions. The provider checks a reason (closest Medicaid provider, ongoing treatment, follow-up after surgery, or care DSS approved) and lists every destination.

A few rules catch people out. Approvals are limited to the towns listed on the form, so list every place the member will go. A licensed provider must sign with a professional designation. MTM will not approve a farther provider when the member was discharged from closer ones for non-compliance. Processing takes two to 10 business days, and urgent forms for dialysis, chemotherapy, or surgery go by email with "Urgent" in the subject line.

### Idaho

Idaho's rule pays only for rides to the nearest medical provider able to perform the needed service, by the most direct route (IDAPA 16.03.26.342, effective July 1, 2026). MTM's Idaho Distance Verification Form (July 21, 2023) must be completed by the referring provider and returned before MTM can prior-authorize the ride. By signing, the provider attests that the destination is the closest appropriate provider, and picks a one-time approval or an expiration date. Questions go to 888-561-8747 or CM-Idaho@mtm-inc.net.

### Iowa

Iowa's rule (441 IAC 78.13(3)"f", effective July 1, 2026) limits rides to the closest qualified Medicaid provider. A farther provider is covered when it is less than 10 miles past the closest one, or when the extra cost is medically justified by a previous relationship, prior experience, the provider's special expertise, or a referral. MTM's Iowa facility page posts no state distance form, so ask MTM's Iowa outreach team, CO-IA@mtm-inc.net, before you send one.

### Minnesota

Minnesota law bars an NEMT provider from driving more than 30 miles to primary care or 60 miles to specialty care unless the local agency authorizes it (Minn. Stat. 256B.0625, subd. 17). Laws 2026, chapter 121 keeps that rule until the state's new NEMT administrator starts, after which the administrator gives the authorization. In the Twin Cities metro and northern Minnesota programs, MTM's Medically Necessary Distance Form is a Letter of Medical Necessity. It asks for the diagnosis, any specialist referral, whether a closer facility could treat the member, why not, and how long treatment will last. The provider signs with a license number and sends it to MTM's Care Management department.

### Missouri

Missouri sets the limit by the member's county and the specialty, from 10 miles to a primary care doctor in an urban county to 100 miles to a cardiologist from a rural one. The state's NEMT manual (posted April 2026) makes MTM drive a member past the limit when the member can prove one of three exceptions: past non-routine care with that provider for a special condition, a primary care referral, or no appointment within 30 days inside the limit. MTM's Missouri facility page says the member may need to explain why and bring a note from the doctor. The full mileage table is on [MTM in Missouri](https://nemtguide.com/brokers/mtm-health/missouri/).

"Exceeds travel standards" and "not the closest MO HealthNet provider available" are both listed denial reasons in the manual, and the member has 90 days from the written denial to ask for a state fair hearing.

### Nevada

Nevada's manual counts an appointment 101 or more miles from home as out-of-area. The medical service needs prior authorization from Nevada Medicaid's fiscal agent or the member's plan first, the ride request is due at least 14 days before travel, and MTM may then ask the referring physician for a distance form. A member with recurring out-of-area treatment can have several trips a month, but no more than five authorized at a time. A rural member going to the closest urban provider needs no distance form. The manual also tells the broker to weigh existing relationships and appointment availability when a provider is within a reasonable distance.

### Wisconsin

Wisconsin's rule limits a member's mileage pay to the nearest Medicaid provider who can give the service, when the member has reasonable access to adequate care there (Wis. Admin. Code DHS 107.23(3)(c)3). MTM's DHS-approved Distance Verification Form asks the referring or treating provider why the member cannot be seen nearer to home, which services and specialties are needed, and whether the approval is one-time or ongoing with an end date. The provider's NPI is required, and MTM posts the form as DHS-approved. DHS announced on May 21, 2026 that it intends to select Verida as the next vendor, and its vendor page, last revised August 25, 2026, set no transition date. See [MTM in Wisconsin](https://nemtguide.com/brokers/mtm-health/wisconsin/).

### Rhode Island and Texas

Both states' MTM facility pages link the standard online form. In Rhode Island, MTM's state contract (effective July 1, 2025) also requires prior authorization of any out-of-state care beyond the approved border communities before MTM schedules the ride. In Texas, the Uniform Managed Care Manual (16.4, version 2.0.1) defines a long-distance trip as one beyond the member's county, the counties next to it, or the plan's service area, approved by the plan or its ride vendor.

## How to get a distance form approved the first time

For the clinic, case manager, or dialysis center filling it out:

1. **Name the reason in medical terms.** Say what care the member needs and why no closer provider offers it: a subspecialty, an established treating relationship, a referral, or no appointment within a reasonable time. A form missing medical information is not processed, MTM's Connecticut form says.
2. **List every destination.** Connecticut limits approvals to the towns on the form, so a second clinic in another town needs to be on it.
3. **Choose ongoing with an end date for a course of treatment.** A one-time approval covers one appointment, so chemotherapy or dialysis at a distant center needs the ongoing box and the date treatment should end.
4. **Send it early.** Two business days in Wisconsin, five on MTM's standard and Nevada forms, and up to 10 business days for processing in Connecticut.
5. **Add an email address.** Connecticut asks for one so MTM can confirm whether the form was approved or denied. Then book the ride through MTM's facility line or its online portal; see the [MTM facility portal guide](https://nemtguide.com/guides/mtm-facility-portal/).

Out-of-state care is a different request. Connecticut uses its Specialized Transportation Form, sent to CTOutofState@mtm-inc.net for DSS approval, and Wisconsin has MTM confirm with DHS or the member's HMO that the visit is authorized. See [out-of-state NEMT trips](https://nemtguide.com/guides/out-of-state-nemt-trips/).

## What a distance form means for your NEMT company

The form decides whether a long trip exists at all. MTM books nothing to a distant address until it reviews the form, so a missing or late form stops the trip at authorization, before it is ever offered to you. If a member asks your company directly for a ride to a faraway specialist, send them back to MTM. Idaho's rule, for one, pays for a trip only when the broker authorizes and schedules it (IDAPA 16.03.26.342.01).

Once approved, long trips carry their own planning:

- **Watch the approval's end date.** A standing ride to a distant dialysis or cancer center stops when the approval ends, and Nevada authorizes no more than five out-of-area trips at a time. Ask the facility to renew before the last approved ride.
- **Plan the day around the miles.** The empty drive back is generally unpaid, so one long ride can eat your day. The [rural NEMT guide](https://nemtguide.com/guides/rural-nemt/) covers loaded miles, wait time, and shared rides.
- **Check the town.** In Connecticut, a ride to a town not listed on the approval is not authorized, even for the same member.
- **Know the private-pay option.** When Medicaid denies a far trip, a family may still pay. Price it with the [long-distance medical transport guide](https://nemtguide.com/guides/long-distance-medical-transport/).

## Frequently asked questions

### Who fills out the MTM distance verification form?

The member's referring or treating health care provider, not the member or the transportation company. Idaho's form goes to the referring provider, who signs that the destination is the closest appropriate provider. Wisconsin's form requires the provider's NPI, and Connecticut does not process a form unless a licensed provider signs it with a professional designation.

### How far ahead does MTM need the distance form?

MTM's standard online form and its Nevada form ask for it at least five business days before the appointment. Wisconsin's form asks for two business days. In Connecticut, MTM takes two to 10 business days to process a Medical Necessity Form, and urgent forms for dialysis, chemotherapy, or surgery go by email with "Urgent" in the subject line.

### How long does an approved distance form last?

As long as the provider marks it. MTM's standard, Nevada, and Wisconsin forms ask whether the approval is one-time or for ongoing treatment, with an end date, and Idaho's asks for one-time or an expiration date. MTM's Connecticut instructions say approvals usually run six months for a temporary diagnosis and one year for a permanent one, decided case by case.

### How many miles can a ride go before the form is needed?

It depends on the state, and some set no number. Connecticut asks for the form past 10 miles in non-rural areas and 20 in rural areas. Minnesota law caps trips at 30 miles to primary care and 60 to specialty care unless they are authorized. Nevada treats 101 miles or more as out-of-area, Iowa covers a farther provider under 10 miles past the closest one or with a medical reason, and Missouri sets limits by specialty.

### Can a member keep a faraway doctor they already see?

Often, with the reason written down. CMS says denying a ride to an established provider can violate freedom of choice when leaving would harm the member. Iowa accepts a previous relationship or a referral, Missouri accepts past non-routine care or a primary care referral, and Nevada tells its broker to weigh existing relationships.

### Does a distance form also cover an out-of-state trip?

Not by itself. Out-of-state care needs its own approval first. Connecticut uses a Specialized Transportation Form that goes to MTM's out-of-state team and DSS for approval. Wisconsin has MTM confirm with DHS or the member's HMO that the visit is authorized, and Nevada requires prior authorization of the medical service before any out-of-area ride.

## Official resources

- [MTM Health: Distance Verification Form (online)](https://securemtm.formstack.com/forms/distance_verification_form)
- [MTM Health: Idaho Distance Verification Form](https://www.mtm-inc.net/wp-content/uploads/2024/03/Idaho-Distance-Verification-Form-FINAL-07.21.2023-1.pdf)
- [MTM Health: Minnesota Medically Necessary Distance Form](https://www.mtm-inc.net/wp-content/uploads/2018/12/MNET-Medically-Necessary-Distance-Form-3.pdf)
- [MTM: Wisconsin Distance Verification Form, online version](https://securemtm.formstack.com/forms/wi_distance_verification_form)
- [MTM Health: Nevada Long Distance Verification Form](https://www.mtm-inc.net/wp-content/uploads/2018/12/NV-Long-Distance-Verification-Form-1.pdf)
- [MTM Health: Connecticut Medical Necessity Form](https://www.mtm-inc.net/wp-content/uploads/2018/12/CT_medical-necessity-form_fillable-2025.pdf)