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CSHCS INFO #24-2018 - DHS-5330 Medical Verification for Transportation

Wed 9/19/2018 8:43 AM

Dear Colleagues,

This INFO impacts beneficiaries who have Medicaid Fee-for-service and do not live in Wayne, Oakland or Macomb County. 

Recently we learned that a DHS-5330 form is required to be completed annually and kept on file at the local MDHHS office for beneficiaries who are not in a Medicaid Health Plan and require NEMT assistance.  The Medical Verification for Transportation (DHS-5330) form is to be signed by the client’s Medicaid-enrolled physician (MD or DO) to verify that Medicaid NEMT is necessary and that the beneficiary meets the requirements for NEMT assistance.  A physician assistant (PA) or nurse practitioner (NP) working under the supervision of the PCP can also verify and sign the form.

LHDs may use the attached DHS-5330 when proactively helping families obtain a signed DHS-5330 for their local DHHS office, to assure the signed form is on file before the family needs to request Medicaid NEMT assistance.   You can locate the beneficiary’s Medicaid Case Number in CHAMPS Client View, under the Demographics tab.

  • One signed form per year is required (every physician does not have to complete a separate DHS-5330)
  • Can be submitted by the PCP or one of the sub-specialists (or PA or NP working under their supervision)
  • Should indicate all conditions for which a beneficiary may need NEMT assistance
  • Should include the site where care outside of Michigan may be required (if out-of-state care is anticipated)
  • Frequency does not have to be exact.  Can estimate the frequency, example ‘3-5 times a month’ or ‘multiple visits, multiple providers, varies each month.’  If frequency later changes, a new form will not be necessary if the form has not expired.

Per the recent MSA Bulletin 18-20, NEMT through the local DHHS office can no longer be denied due to not having a DHS-5330 on file before the appointment.  The DHS-5330 can be completed and returned to the authorizing party (local DHHS) up to 10 business days after the appointment.

If the local DHHS office has questions about proper use of the DHS-5330 form, please email Lida Momeni at

Medicaid Health Plan members must contact their health plan for NEMT assistance.  Clients with Medicaid fee-for-service who live in Wayne, Oakland or Macomb County may contact Logisticare Solutions at 866-569-1902, for information regarding medical verification requirements.

If you have additional questions, please contact me at 517 335 9408 or email




Sherry Kertesz

Transportation Analyst

Children’s Special Health Care Services (CSHCS)

Tel: 517-335-9408

Fax: 517-335-8055