MTM Level of Need Form in 2027: When a Patient Needs One, How to Fill It Out, and Each State's Version

MTM Health assigns each member the most cost-effective ride that fits their needs. A member who can drive gets gas mileage, a member near a bus line gets a pass, and a member who can walk to the car gets a sedan. The Level of Need form is how a clinic tells MTM the member needs more: a wheelchair van, a stretcher van, or a non-emergency ambulance.

When MTM asks for a Level of Need form

The trigger is the same on most of MTM’s state pages. When a member says they cannot use public transportation or mileage reimbursement, MTM asks the member’s health care provider to fill out a Level of Need (LON) form. As of October 2026, MTM’s facility pages for Iowa, Missouri, Nevada, Rhode Island, Idaho, Wisconsin, and northern Minnesota say so. Its Texas page says a provider may be required to complete one, its Connecticut page asks for a Medical Necessity Form, and its metro Minnesota page calls the form a Transportation Evaluation Form.

MTM’s Iowa page lays out the ladder the form moves a member up:

1. Gas mileage reimbursement when the member, a friend, or family can drive.
2. Public transit when home and destination are near a bus stop and the member can walk there safely alone.
3. Sedan when the member can walk between the door and the vehicle.
4. Wheelchair vehicle when the member uses a mobility device.
5. Stretcher van when the member is confined to a bed and cannot transfer to a wheelchair.
6. Non-emergency ambulance when the member needs medical care on the way.

States add their own rules on top. Missouri’s NEMT manual (April 2026) bars the broker from assigning public transit for a high-risk pregnancy, a pregnancy past the eighth month, a high-risk heart condition, severe breathing problems, or a walk of more than four blocks or half a mile to the stop. The MTM in Missouri page covers the rest of that state’s rules.

For how medical necessity paperwork works across all brokers, see the medical necessity form entry.

What the standard form asks

The standard LON is one page with a “Dear Medical Professional” letter on top. It asks the clinician about:

• Patient information. Name, date of birth, Medicaid ID, phone, trip number, and address.
• Physical abilities and equipment. Which devices the patient uses: walker, crutches, cane, portable oxygen, service animal, manual wheelchair, leg brace, an electric wheelchair or scooter with its weight, or a bariatric wheelchair with its weight. Then whether the patient needs trained personnel to use them safely, can self-transfer from a wheelchair, and can get out of an unsafe situation.
• Weather. Whether heat or cold limits the patient’s mobility enough to rule out a mode in some seasons.
• Thinking and senses. Limits in vision, hearing, alertness, confusion, or memory that affect a mode.
• Mental and behavioral health. Limits that affect a mode.
• Pregnancy. Complications that make it high risk.
• Time frame. Temporary through a date, or permanent. The form says to choose permanent only if the condition will not improve.

The clinician prints their name and credentials, adds a phone number and a facility or individual NPI where one applies, signs, and dates it. The completed form goes to fax 1-877-406-0658, attention Level of Need, and questions go to MTM at 1-888-561-8747. MTM’s healthcare provider page also links an online version of the standard form.

The ambulance and stretcher version

Riders who may need a stretcher van or an ambulance get a longer form. It asks for the diagnosis, whether it is permanent or temporary through a date, and any muscular, respiratory, cardiac, or cognitive impairment. Then it asks:

• Can the patient sit in a wheelchair, and if not, why not?
• Does the patient need an EMT or paramedic watching during the ride?
• Does the patient need oxygen during the ride?
• Must the patient be lifted or carried up or down stairs to leave home or the building?
• Can the patient transfer into the vehicle without help?
• Does the patient need life-sustaining equipment, a reclining position (for medical or psychiatric reasons), or a personal attendant?

The signer certifies the answers are true and complete and that Medicaid or Medicare funded travel may be ordered from them. A separate line records who filled out the form, with their title and phone. It goes to fax 1-866-453-0247, attention Ambulance/Stretcher Authorization Specialist, and MTM’s Ambulance Utilization Management department answers questions at 1-888-561-8747. MTM’s Iowa and Rhode Island pages post this version. Missouri’s manual says to contact the broker for its Stretcher Assessment Form.

Each state’s version

Several states post their own versions of the form. As of October 6, 2026, MTM’s facility pages offer these:

State	Form posted	Send it to
Connecticut	Medical Necessity Form (revised July 18, 2023), also used as the LON and distance form	Fax 860-724-2159 or CM-Connecticut@mtm-inc.net
Idaho	Level of Need Assessment Form (2023 version)	Fax 1-877-406-0658
Iowa	Standard LON and ambulance and stretcher LON	Fax 1-877-406-0658; stretcher form fax 1-866-453-0247
Minnesota (metro)	Level of Need form (.doc file), which the page calls a Transportation Evaluation Form	Fax 1-651-203-1262, at least 72 hours ahead
Missouri	Level of Need Assessment Form	Fax 1-877-406-0658
Rhode Island	Online standard LON and ambulance and stretcher LON	Online form; stretcher form fax 1-866-453-0247
Texas	Online standard LON for the health plans MTM serves	Online form
Wisconsin	Standard LON (updated May 1, 2024) and ambulance and stretcher LON, also online	Fax 888-506-7708

Wisconsin

Wisconsin’s version asks extra questions: whether the patient can walk up to half a mile, can stand for a long time, and would benefit from MTM’s one-on-one training on using the bus. Where it applies, the clinician must describe a diagnosis that supports the limits, such as a high-risk pregnancy or recent surgery, and give a due date for a pregnant patient. The time frame is a date, 1 month, 3 months, 1 year, or 3 years. The form must reach MTM at least two business days before the appointment.

Wisconsin DHS announced its intent to select Verida as the next NEMT manager on May 21, 2026, and its vendor page, revised August 25, 2026, gave no switch date. Members keep booking with MTM until DHS sets one. See MTM in Wisconsin.

Idaho

Idaho’s form adds a half-mile walking question, an attendant question, and a due date for pregnant patients. It also states the cost of a late form: if MTM does not receive it before a temporary certification expires, the member’s mode reverts to the lowest mode of transportation.

Minnesota

The metro Minnesota page posts a .doc file titled Level of Need Assessment Form, last saved in March 2021. It asks for the diagnosis and any recent hospitalizations or surgeries, whether the patient lives alone, in a nursing facility, in a group home, or in rehab, and the number of steps at home. It also asks for a 1 to 5 rating of alertness, memory, and confusion. It goes to fax 1-651-203-1262, attention Contact Center, and must arrive at least 72 hours before the appointment. Northern Minnesota’s page names the Level of Need form in its questions but posts only the attendant and distance forms.

Connecticut

Connecticut uses one Medical Necessity Form in four parts. Part A, the member’s information, must be complete or the request is denied. Part B names the facility contact, and an email address there gets you notice when the form is approved or denied. Part C covers the ride type, and Part D covers trips past the mileage limit. MTM’s instructions add these rules:

• The bus comes first. A member within 0.75 miles of a bus stop whose appointments match bus routes qualifies for public transit unless a documented physical or mental limit rules it out.
• The reason must be valid. Opioid dependence (F11.20) alone is denied as a reason to skip the bus. Being immunocompromised is accepted.
• Distance needs a reason. Part D is required for trips over 10 miles in a non-rural area or 20 miles in a rural one, and approvals cover only the towns listed, so list every destination. A member discharged from a closer provider for not following treatment is not approved to travel farther.
• Timing. Processing takes 2 to 10 business days. For urgent trips such as dialysis, chemotherapy, or surgery, email the form to CM-Connecticut@mtm-inc.net with Urgent in the subject line.

Illinois

MTM’s healthcare provider page marks two forms as Illinois only: the Certificate of Transportation Services and the Physician Certification Statement, both state Healthcare and Family Services forms. See the Illinois Certificate of Transportation Services guide for which one a ride needs.

Attendant forms

A rider who needs a second person on board needs a separate form in some states:

• Wisconsin. The Attendant/Escort Medical Necessity Form (updated May 1, 2024) asks whether the member needs help for a physical disability, supervision for a developmental disability or a cognitive issue, or help for mental health needs, and for how long. It goes to fax 888-506-7708, and MTM cannot arrange the attendant until it processes the form.
• Minnesota. MTM’s Medically Necessary Attendant Form, posted for both its Minnesota service areas, asks for the diagnosis, the medical reason for the extra passenger, and what that person will do. It goes to MTM’s care management team at fax (651) 203-1262 or mnetcaremanagement@mtm-inc.net.
• Nevada. MTM’s Nevada page links an online Medically Necessary Attendant Form.

How an escort changes your trip and seats is covered in escorts and caregivers. Trips to a faraway specialist use a different form: see the MTM distance verification form.

How to fill it out so it goes through

1. Answer every question legibly. MTM’s standard letter asks for a complete form with supporting information, and Connecticut denies a request with missing member fields.
2. Describe what the patient cannot do. A diagnosis alone does not carry a request, as Connecticut’s opioid example shows. Name the device, the distance the patient can walk, and the help they need.
3. Pick the time frame honestly. Use permanent only when the condition will not improve, and give an end date for a cast, a recent surgery, or a pregnancy.
4. Sign with credentials. Print the name and credentials, and add the NPI where one applies. Connecticut does not process a form without the signer’s professional designation.
5. Send it early. Wisconsin needs the form two business days before the appointment, and Connecticut takes up to 10 business days.

What the ride company should know

A ride company does not fill out the LON, and Connecticut’s form says it is the member’s job to make sure MTM receives it. The form still decides your work, because MTM assigns the mode from it and you must run the trip in that mode. MTM’s Virginia provider handbook (approved August 10, 2026) bars providers from changing the assigned mode without approval, and says an unapproved mode or a substituted vehicle may mean non-payment or corrective action.

• Watch the dates. A Rhode Island member gets the requested mode for up to two weeks while the doctor completes the form. In Idaho, a member whose temporary approval lapses without a new form drops to the lowest mode of transportation.
• Know your regular riders’ dates. For dialysis and other standing order riders, ask the clinic to send a new LON before a temporary date passes. See standing orders.
• Give facilities the right fax line. The standard form, the stretcher form, Wisconsin, Connecticut, and metro Minnesota each go to a different fax line.
• Join MTM first. Joining MTM’s network is covered on the MTM Health page.