CurrentAlliance HealthPolicy 2A-3

Out-of-State (OOS) Medicaid Services

Governs coverage of out-of-state medical services for NC Medicaid beneficiaries, including criteria for services within 40 miles of the NC border and other out-of-state care; affects providers and beneficiaries under NC Medicaid.

Policy Summary

PayerAlliance Health

PolicyOut-of-State (OOS) Medicaid Services

Policy CodePolicy 2A-3

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain prior approval via NCTracks with a signed Letter of Medical Necessity and supporting records for non-emergent out-of-state services and nonemergent transport.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

40 milesBorder distance

PA requiredNon-emergent OOS

enrollment requiredProvider enrollment

42 U.S.C. §1396d(r)EPSDT authority

Coverage and Medical Necessity Criteria

Specific Criteria Covered

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Specific OOS coverage: a. Services not available in North Carolina.

As soon as medically appropriate, the beneficiary shall return to North Carolina; services are covered only when meeting Subsection 3.2.1 criteria.

Specific OOS coverage: b. The beneficiary is out of state and requires emergency medical care as defined by the policy.

Reference definition of Emergency Medical Condition; covered without prior approval when emergent.

Specific OOS coverage: c. The beneficiary is out of state and the beneficiary's health would be endangered if care were postponed until return to North Carolina.

Covered when postponement would endanger health.

Specific OOS coverage: d. The beneficiary is out of state and the beneficiary's health would be endangered if travel were undertaken to return to North Carolina.

Covered when travel to return would endanger health.

Foster child exception: e. A foster child who is a ward of the State of North Carolina and living in a foster home more than 40 miles from the NC border — out-of-state services are covered without prior approval.> 40 miles

Foster child exception to prior approval requirement.

Not Covered Conditions

Medicaid does not cover the procedure, product, or service when:

General noncoverage: a) The beneficiary does not meet the eligibility requirements listed in Section 2.0; b) The beneficiary does not meet the criteria listed in Section 3.0; c) The procedure, product, or service duplicates another provider's procedure, product, or service; d) The procedure, product, or service is experimental, investigational, or part of a clinical trial.

These are general triggers for denial or noncoverage.

Out-of-state specific not covered: Out-of-state services rendered by a provider or facility that is not enrolled in NC Medicaid are not covered.

Providers/facilities must be enrolled in NC Medicaid to be covered.

Specific services not covered when OOS: The following services are not covered when provided by out-of-state providers: Children's Developmental Service Agency (CDSA); Community Alternatives Program (CAP); Program of All-Inclusive Care for the Elderly (PACE); Private Duty Nursing (PDN); Durable Medical Equipment (DME); and services rendered outside an emergency department or inpatient stay resulting from an ED evaluation without prior approval.

These are explicit out-of-state service exclusions.

Prior Approval Criteria and Limits

Prior approval is required and granted under these operational rules:

PA submission requirements: The NC referring provider must submit the out-of-state prior approval request via the NCTracks Provider Portal and include the signed Letter of Medical Necessity (LOMN) plus all supporting health records demonstrating the beneficiary meets the specific criteria in Subsection 3.2.

LOMN must include beneficiary identifiers, current clinical status, prior NC treatment, OOS provider/facility and NPI, reasons treatment cannot occur in NC, and anticipated treatment plan with CPT/HCPCS/revenue codes and length of stay.

Provider/facility enrollment: The out-of-state facility and rendering provider(s) must be enrolled in NC Medicaid with an active NPI in NCTracks at the time of prior approval submission; if not active, the prior approval request cannot be submitted.

Prior approval is granted only for the specific facility requested and is non-transferable; transfers require additional prior approval.

Reauthorization and authorization limits: NC physicians must request reauthorization and provide an updated LOMN before the end of the current authorization period for continued services; subsequent or inpatient treatment options require separate submission via NCTracks with clinical information and LOMN prior to treatment.

If Medicaid is not the primary payer, prior approval will not be granted; Medicaid is payer of last resort.

Transport PA requirements: A prior approval is required for nonemergent air or ground transport to out-of-state services and a separate prior approval is required for air or ground transport returning to a NC Medicaid facility; emergent transportation does not require prior approval.

NC provider must request transport PA through the NCTracks provider portal.

Prior Approval Criteria and Limits

Covered when following conditions met

Out-of-state treatment billing: Out-of-state treatment for a NC Medicaid beneficiary requires prior approval unless the treatment was received in an emergency department and resulted in discharge or admission.

Exception applies for ED visits that result in discharge or admission; otherwise PA required.

Provider enrollment: In-state and out-of-state providers must be currently enrolled in NC Medicaid to bill for services rendered to NC Medicaid beneficiaries.

Services by providers not enrolled in NC Medicaid may be billed to the beneficiary or legal guardian and may result in denial of payment to the provider.

Emergent services claims documentation: When submitting a claim for emergent services, the provider must submit the beneficiary's face sheet, emergency department record, observation record, admission history and physical, discharge summary, and any other relevant information demonstrating the condition met the definition of emergent services per 42 CFR 489.24(b).

Hospital providers should indicate true emergency using emergency codes on claim forms and follow NCTracks billing guidance.

Coding, Claims, and Billing Identifiers

Attachment A referenced (claims-related coding details)mixed

No codes listed

Codes to be documented for anticipated treatmentmixed

CPT	Referenced — anticipated CPT codes to be documented in LOMN
HCPCS	Referenced — anticipated HCPCS codes to be documented in LOMN
revenue	Referenced — anticipated revenue codes to be documented in LOMN

Claim Typemixed

CMS-1500	Professional claim form / 837P transaction
UB-04	Institutional claim form / 837I transaction

Coding systemsmixed

ICD-10-CM	Diagnosis coding to highest specificity
PCS	Procedural Coding System (PCS) reporting to highest specificity
CPT	Current Procedural Terminology — use most specific procedure code
HCPCS	HCPCS Level II — use most specific code; unlisted codes when applicable

Regulatory referencesmixed

42CFR489.24(b)

Regulatory definition referenced for emergent services documentation

Border provider distance threshold — 40 miles

Border provider distance thresholdProviders located within 40 miles of the North Carolina border are reimbursed to the same extent and under the same conditions as services provided in NC (40 miles).

Contiguous states notedServices within 40 miles of the NC border in the contiguous states of Georgia, South Carolina, Tennessee, and Virginia are covered as in‑state.

Out-of-State provider definitionProviders located more than 40 miles from the NC border are considered out-of-state providers and are not covered by the border provider rule.

Provider Responsibilities, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required for Out-of-State Services

Prior approval is required for Out-of-State (OOS) Services. The NC referring provider must obtain prior approval before rendering non-emergent out-of-state services. Prior approval is granted only for the specific facility requested and is not transferable to another facility; transfers require additional prior approval. If the beneficiary becomes eligible for other health coverage, Medicaid is payer of last resort and prior approval will not be granted when NC Medicaid is not the primary payer. Referral by a primary care provider does not constitute prior approval.

Prior approval exemption: Foster children who are wards of the State of North Carolina and living in a foster home more than 40 miles from the NC border may receive out-of-state services without prior approval except when the specific procedure or service itself requires prior approval.
Prior approval is not required for emergent treatment received in an emergency department that results in discharge or admission.

Documentation Required

Eligibility Verification and EPSDT Documentation

Providers shall verify each Medicaid beneficiary's eligibility each time services are rendered. For beneficiaries under 21 years of age, EPSDT protections may require coverage of services otherwise limited by policy when medically necessary; however, EPSDT does NOT remove any prior approval requirements — prior approval must still be obtained when the service normally requires it. Providers should consult NCTracks and the EPSDT provider page for additional guidance.

Verify beneficiary eligibility at every encounter via NCTracks.
When EPSDT applies, include documentation showing medical necessity and how the requested service meets EPSDT criteria (corrects or ameliorates a defect, illness, or condition).

Documentation Required

Submission of Records and Provider Enrollment Requirements

Submit the prior approval request and all supporting health records to the Department of Health and Human Services (DHHS) Utilization Review Contractor via the NCTracks Provider Portal. The NC referring provider must submit the OOS prior approval request; the OOS facility and rendering provider(s) must be enrolled and active in NC Medicaid at time of submission (active NPI in NCTracks). Requests cannot be submitted for providers not enrolled in NC Medicaid.

Include ALL required documentation listed in the Letter of Medical Necessity (LOMN) signed by the NC referring physician.
Ensure the OOS facility and OOS rendering provider NPIs are active in NCTracks before submission.

Documentation Required

Letter of Medical Necessity (LOMN) Content Requirements

The NC referring provider must include a Letter of Medical Necessity (LOMN) signed by the NC referring physician with the prior approval submission. The LOMN must contain beneficiary identification, current clinical status and diagnosis, description of treatment provided in NC, the OOS physician(s) and facility with NPI(s), reasons why treatment cannot be provided in NC, and the anticipated treatment plan including CPT/HCPCS/revenue codes and expected inpatient or outpatient length of stay.

LOMN must include: beneficiary name, NC Medicaid ID, date of birth, clinical status/diagnoses, NC treatment rendered, OOS provider(s) and facility plus NPIs, justification why NC care is unavailable, anticipated treatment plan and billable codes.

Billing Rule

Claims Submission Standards and Documentation for Emergent Services

Claims must follow the NCTracks Provider Claims and Billing Assistance Guide and National Uniform Billing Guidelines. When submitting claims for emergent services, include the beneficiary face sheet, emergency department record, observation record, admission history and physical, discharge summary, and any other documentation demonstrating that the condition met the definition of emergent services. In-state and out-of-state providers must be enrolled in NC Medicaid to bill for services rendered to NC Medicaid beneficiaries; services by providers not enrolled in NC Medicaid may be billed directly to the beneficiary or legal guardian.

Indicate true emergency on claim or UB/HCFA forms as required when emergency exception is claimed.
Out-of-state providers reimbursed according to NC Medicaid State Plan; see State Plan and fee schedules for rates.

Denial Risk

Denial and General Noncoverage Triggers; Out-of-State Exclusions

Services will be denied or are not covered when the beneficiary does not meet Section 2.0 eligibility requirements, does not meet Section 3.0 coverage criteria, the service duplicates another provider's service, or the service is experimental, investigational, or part of a clinical trial. Medicaid will not cover out-of-state services rendered by a provider or facility that is not enrolled in NC Medicaid. Certain programs and services provided by out-of-state providers are specifically excluded (e.g., CDSA, CAP, PACE, PDN, DME) and services provided outside an emergency department or inpatient stay resulting from an ED evaluation are not covered without prior approval.

Denial triggers: failure to meet Section 2.0 or 3.0, duplicate services, experimental/investigational procedures, provider not enrolled in NC Medicaid.
Specific noncovered OOS services: Children's Developmental Service Agency (CDSA); Community Alternatives Program (CAP); Program of All-Inclusive Care for the Elderly (PACE); Private Duty Nursing (PDN); Durable Medical Equipment (DME).

Key Definitions

Emergency Medical Condition — definition

DefinitionEmergency Medical Condition: acute symptoms of sufficient severity (including severe pain) such that a prudent layperson could reasonably expect that absence of immediate medical attention would result in serious impairment to bodily functions or serious dysfunction of any body organ or part.

Pregnancy exceptionFor Medicaid beneficiaries who are pregnant and having contractions: (1) inadequate time to safely transfer to another hospital before delivery; or (2) transfer may threaten health or safety of the woman or her unborn child.

StandardApplies the prudent layperson standard to determine need for immediate medical attention.

Out-of-State providers / Border providers — Border providers within 40 miles treated as in-state

Border provider ruleBorder providers located within 40 miles of the NC border are reimbursed to the same extent and under the same conditions as services provided in NC.

Geographic scopeThe 40‑mile border rule applies to providers in the contiguous states (examples include Georgia, South Carolina, Tennessee, and Virginia).

Out-of-state distinctionProviders located more than 40 miles from the NC border are treated as out-of-state providers and do not qualify for the border provider reimbursement treatment.

Letter of Medical Necessity (LOMN) — signed letter content requirements

Author and signatureLOMN must be signed by the NC referring physician and submitted with the OOS prior approval request.

Beneficiary identifiersMust include the beneficiary's name, NC Medicaid number, and date of birth.

Clinical and treatment detailsMust document the beneficiary's current clinical status with diagnosis(es), description of medical treatment rendered in NC, reasons why the beneficiary cannot be treated in NC, and the anticipated treatment plan including CPT, HCPCS, and revenue codes and inpatient or outpatient length of stay.

OOS provider/facility infoMust include the name(s) of the out-of-state physician(s) and facility and their National Provider Identifier (NPI) number(s).

Transport for emergent situations — does not require prior approval

Prior approval not required for emergent transportEmergent transportation does not require prior approval.

Nonemergent transport PAA prior approval is required for nonemergent air or ground transport for out-of-state services and a separate PA is required for return transport to a NC Medicaid facility.

Submission routeThe NC provider must request the PA through the NCTracks provider portal for transportation services when PA is required.

Emergent services — definition and documentation requirement per 42 CFR 489.24(b)

Regulatory definition requiredEmergent services are those that meet the definition of emergent services per 42 CFR 489.24(b); claims must demonstrate the condition met this definition.

Required documentation for claimsWhen submitting a claim for emergent services, providers must include the beneficiary's face sheet, emergency department record, observation record, admission history and physical, discharge summary, and any other relevant information demonstrating emergent status.

Prior approval exceptionOut-of-state treatment requires prior approval except when treatment was received in an emergency department that resulted in discharge or admission.

OpenPayer

Out-of-State (OOS) Medicaid Services

Coverage and Medical Necessity Criteria

Coding, Claims, and Billing Identifiers

Provider Responsibilities, Prior Authorization, and Documentation

Background and Scope

Key Definitions