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Alaska Medicaid Travel COMN and Escort Certification

Alaska Medicaid requires this certification when a member's travel request bypasses the closest available provider, goes out of state, includes an escort for a member 18 or older, or asks for two escorts. The treating provider explains why the destination is needed, the appointment pattern and any escort's role. It accompanies online and telephone travel authorization requests and can cover a period of up to one year from signature.

Who completes it

The requesting provider's office enters member, provider and appointment details in Sections 1 and 2. The treating provider, or a registered nurse working under the delegation of the treating physician, osteopath or podiatrist, completes Section 3 and signs the attestation.

Submitting and payment

How to submit it
The form goes with an online or telephone travel authorization request to the Alaska Medicaid fiscal agent; requests sent by fax use the travel fax packets instead of this form.
Who pays
The form sets no fee for the provider; it supports authorization of the member's travel, and Alaska Medicaid does not compensate escorts themselves.

Good to know

  • One form covers each certification period, up to one year from the signature date, and a new one is needed when the member's condition or treatment plan changes.
  • For routine appointments, a plan of care is needed after the initial evaluation. The provider can attach it, cite a prior submission date, or enter the plan details in Section 2c(2).
  • A single escort for a member 17 or younger is approved under 7 AAC 120.430 without this justification; adults and dual escorts need documented functional limitations and the escort's role.
  • Escort transport is not paid when the member travels by ground or air ambulance. Chart notes may be added but do not replace the written escort rationale.

Get the official form

Download the current version from the source each time; forms change without notice.

Travel Certification of Medical Necessity

Official pagePDF

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

How long is an Alaska Medicaid Travel COMN valid?

The certification period is set in Section 3 and cannot exceed one year from the date the treating provider signs. Escort dates have the same one-year limit. A new form is required for each certification period, or sooner if the member's condition or treatment plan changes during that time.

When is a Travel COMN needed for an escort?

It is needed for an escort accompanying a member 18 or older and for dual escorts. The provider checks an escort rationale, such as inability to ambulate from a chronic condition, active chemotherapy or radiation, or an outpatient sedated procedure, and describes the member's functional limitations. Behavioral health reasons must be completed and signed by the treating behavioral health provider.

Can the Travel COMN be faxed?

No. The form itself says not to use it for requests submitted by fax. Fax requests go through Alaska Medicaid's out-of-area and local-area travel service authorization fax packets, which carry their own documentation. The Travel COMN is for online and telephone requests and for changes to an existing authorization.