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Minnesota Department of Human Services Provider Manual
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Out-of-State Providers

Revised: 12-06-2012

This section details the conditions under which Minnesota Health Care Programs (MHCP) pays out-of-state health care providers for services rendered to fee-for-service MHCP recipients. Out-of-state providers must contact the managed care organization (MCO) for enrollment and payment information when the MHCP recipient is enrolled in an MCO.

Minnesota requires health care providers, including out-of-state providers, to be aware of and follow certain guidelines. Review the following sections for these requirements:

  • Advance Directives
  • Fraud
  • MHCP covers services provided by an out-of-state provider to MHCP recipients who are outside of Minnesota or their local trade area under the following circumstances:

  • • The provider must enroll in MHCP and follow all program guidelines
  • • The services must be medically necessary
  • • The services are provided in response to an emergency while the recipient is out of the state of Minnesota
  • • Except for emergency services, out-of-state providers must obtain authorizations before providing MHCP covered services
  • • The services are not available in Minnesota or the recipient’s local trade area, and the attending physician determined medical necessity and obtained authorization from the medical review agent (the recipient’s county is responsible for travel expenses associated with obtaining the out-of-state services)
  • • The services are required because the recipient’s health would be endangered if required to return to Minnesota for treatment
  • MHCP has many enrolled providers who are located outside of Minnesota but who perform services for MHCP recipients who did not leave the state or their local trade area for those services.

    For medical supplies/equipment, MHCP considers the place of service to be the recipient’s home, thus provided in Minnesota regardless from where the provider ships the product. MHCP does not consider these medical supplies/equipment to be out-of-state.

    For laboratory services, providers often send samples from recipients in Minnesota outside of Minnesota for processing. Because the samples are drawn in Minnesota, MHCP does not consider these lab services to be out-of-state.

    For teleradiology services, the technical component, where the imaging is performed, is in-state, while the professional component, the reading of the image, may be performed out-of-state. MHCP does not consider these radiologic services to be out-of-state.

    Eligible Providers

    To receive MHCP payment for services to MHCP recipients, eligible providers, including out-of-state providers, must enroll. An out-of-state provider may apply for MHCP retroactively to the date services were provided to an eligible MHCP recipient. To enroll, an out-of-state provider must:

  • • Comply with licensing and certification requirements of the state where the provider is located
  • • Complete, sign, and fax the MHCP Enrollment Application and Provider Agreement to MHCP
  • • Receive MHCP Provider Enrollment approval
  • Eligible Recipients

    Out-of-state providers may render emergency medical services to recipients enrolled in a MCO. Out-of-state providers may render emergency services to restricted recipients without referral from the primary care physician if these services are provided in response to a condition that, if not immediately diagnosed and treated, could cause a person serious physical or mental disability, continuation of severe pain, or death. The Minnesota Restricted Recipient Program office may require documentation of the emergency situation in order to determine payment of the claim.

    Covered Services

    Except for emergency services, out-of-state providers must obtain authorizations before providing MHCP covered services. Review MHCP Benefits at-a-glance for a list of MHCP covered services. All health care services must be medically necessary. Requests for authorization of services provided outside of Minnesota must include documentation establishing medical necessity and the unavailability of that service in Minnesota or the contiguous counties.

    In addition to the Benefits At-a-glance information, the following information applies to out-of-state providers:

  • • If a procedure is to be performed in an out-of-state hospital, the authorization request must include evidence that the hospital meets the requirements of Medicare, UNOS, and the Foundation for the Accreditation of Cellular Therapy (FACT)
  • • Chemical health treatment programs must contact the Alcohol & Drug Abuse Division or the Minnesota county of their choice for additional information
  • Noncovered Services

    MHCP does not cover out-of-country care. Out-of-country care occurs when an MHCP recipient receives services or supplies outside the United States.

    Billing

    Already enrolled out-of-state providers must submit claims to MHCP electronically through MN–ITS using either MN–ITS Direct Data Entry or following X12 and Minnesota’s Uniform Companion Guides.

    Providers enrolling specifically to serve an MHCP recipient out-of-state may bill electronically, per above, or for a one-time billing, may submit a paper claim to:

    DHS – HCO Claims
    PO BOX 64993
    St Paul MN 55164-0993

    MHCP will accept paper claims only from out-of-state providers who do not routinely bill MHCP.

    MHCP will not make payments to providers, financial institutions, or entities located outside of the United States.

    Legal References

    Minnesota Rules 9505.0170 – Medical Assistance Payments; Applicability
    Minnesota Rules 9505.0215
    – Covered Services; Out-of-state Providers
    Minnesota Rules 9505.5000
    – Conditions for MA and GAMC Payment; Applicability
    Minnesota Rules 9505.5025
    – Prior Authorization Requirements for Health Services Provided Outside of Minnesota
    MS 256B.03
    , subd.4 – Prohibition on payments to providers outside of the United States
    MS 645.001
    – Applicability to Rules
    MS 645.17
    – Presumptions in Ascertaining Legislative Intent
    Title XIX § 1902(a)(16)
    – State Plans for Medical Assistance
    42 CFR 431.52
    – Payments for services furnished out of State

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