An approved Certification of Need Form is required before a member can receive and be reimbursed for any special transportation services and are good for up to one year.

This form is to be completed by a healthcare professional only. Minnesota State Law prohibits reimbursement of special transportation for Minnesota Health Care Program recipients without a current and approved Certification of Need Form that has been completed by a healthcare professional.

The following health care providers directing the healthcare of the member may complete the form:

Attending Physician (MD)
Clinical Nurse Specialist (CNS)
Physician Assistant (PA)(PAC)
Advanced Practice Registered Nurse (APRN)
Nurse Practioner (NP)
Certified Nurse Midwife (CNM)
Physician Extender
Licensed Independent Clinical Social Worker (LICSW)
Licensed Marriage and Family Therapist (LMFT)
Licensed Professional Clinical Counselor (LPCC)
Licensed Psychologist (LP)
Mental Health Rehabilitative Professional
Psychiatric Mental Health Nurse Practitioner (PMHNP)
Psychiatrist or Tribal Certified Professional

Note: Care Coordinators working on behalf of Medica may not complete the Certification of Need form.

Questions about Special Transportation

Healthcare providers with questions should contact the Medica Provider Service Center at 800-458-5512.

Medica members and member representatives should call the Customer Service number located on the back of their member ID card.

As of June 1, 2018 this Certificate of Need form must be submitted electronically by clicking the Submit button at the end of the form. Other forms of submission are no longer accepted.

Certification of Need Form for Special Transportation

According to MN Rules 9505.0315, subp 1(F), special transportation means the transport of a recipient who, because of a physical or mental impairment, is unable to use a common carrier and does not require ambulance service. For the purposes of item F, "physical or mental impairment" means a physiological disorder, physical condition, or mental disorder that prohibits access to or safe use of common carrier transportation.

Does the member require special transportation according to MN Rules 9505.0315, subp 1(F)?

Medica Member Details

First name:

Last name:

Date of birth:

Group number:

Member ID number:

Medica Member Health Condition Details

Select the transportation mode:

Is the member's health condition permanent?

Enter the ICD-10 primary diagnosis code(s) requiring special transportation. Enter up to four diagnosis codes:

Please describe how the member's health condition requires special transportation:

Anticipated first date of service:

Authorizing Provider Details

Enter the following information for the provider completing the form and authorizing the services. All information is required.

First name:

Last name:

Specialty:

National Provider Identification (NPI) number:

Facility or clinic name:

Phone number:

Email address:

Confirm email address:

Provider Signature

I certify that I have reviewed the provided member’s medical history and condition, and the member meets Minnesota Statute section 9505.0315, subp 1(F) criteria for Special Transportation services.

As of June 1, 2018 this Certificate of Need form must be submitted electronically by clicking the Submit button below. Other forms of submission are no longer accepted.

Provider full name:

Today's date: