Out-of-State Providers

Revised: May 19, 2021

· Overview

· Eligible Providers

· Eligible Members

· Covered Services

· Noncovered Services

· Billing

· Legal References

Overview

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 members. 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 members 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 member 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 member’s local trade area, and the attending physician determined medical necessity and obtained authorization from the medical review agent (the member’s county is responsible for travel expenses associated with obtaining the out-of-state services)

· The services are required because the member’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 members who did not leave the state or their local trade area for those services.

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

For laboratory services, providers often send samples from members 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 members, eligible providers, including out-of-state providers, must enroll in MHCP. An out-of-state provider may apply for MHCP retroactively to the date services were provided to an eligible MHCP member. 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 Members

Out-of-state providers may render emergency medical services to fee-for-service MHCP members and members enrolled in a Managed Care Organization (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 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.

The following information applies to out-of-state providers in addition to the benefits at-a-glance information:

· 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 member 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.

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
Minnesota Statutes 256B.03, subdivision 4 – Prohibition on payments to providers outside of the United States
Minnesota Statutes 645.001 – Applicability to Rules
Minnesota Statutes 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