Out-of-Network (OON) Behavioral and Physical Health Services Coverage Criteria
Customize your policy alerts
Sign up for all chocchildrenshospitalorangecountyhealthalliance policy alerts
Know when chocchildrenshospitalorangecountyhealthalliance releases new policies or updates existing guidance.
Monitor payer policy activity
Defines Alliance Health's coverage determination principles for emergency and non-emergency out-of-network services for behavioral and physical health, including when prior authorization is required and circumstances that permit OON coverage.
Expanded the policy to have applicability to Behavioral Health Services as well as Physical Health services.
Coverage Conditions and Requirements
Coverage Conditions
Covered when ALL of the following are met
References NCDHHS definition of medical necessity and community practice standards
In-state out-of-network coverage conditions
- There are no in-network providers that can furnish that specific service.
From Out-of-Network Services: Behavioral Health (in-state)
- The service is necessary for continuity of care.
From Out-of-Network Services: Behavioral Health (in-state)
Out-of-state out-of-network coverage conditions
- The medically necessary service or care is not available in NC.
Out-of-State OON (i)
- The beneficiary is out of state and requires emergency medical care.
Out-of-State OON (ii)
- The health of the beneficiary would be endangered if the care were postponed until the beneficiary returns to NC.
Out-of-State OON (iii)
- The health of the beneficiary would be endangered if travel were undertaken to return to NC.
Out-of-State OON (iv)
- The member is in foster care and placement is more than forty (40) miles from the NC border.
Out-of-State OON (v)
See Limitations and Exclusions
All out-of-network (OON) services are subject to ongoing utilization and/or medical necessity review. This review applies to both behavioral and physical health OON services and is used to determine whether continued coverage is appropriate based on clinical need and plan provisions.
Medical necessity determinations follow the NCDHHS definition and North Carolina community practice standards and are used to decide whether a requested service meets coverage criteria. Alliance reviews prior authorizations using NCDHHS CCPs, NCDHHS state-funded service definitions, and MCG Health guidance when available; if those sources do not provide necessary criteria, Alliance's own CCPs will be applied. Services that do not meet these medical necessity standards may be considered not medically necessary and denied.
Behavioral Health Out-of-Network Services Criteria
Coding and Billing References
Prior Authorization, Documentation, and Denials
Obtain prior authorization for non-emergency OON services
Prior authorization is required for these out-of-network services; providers must obtain PA before rendering non-emergency services. Prior authorization is not required for services rendered in emergencies (physical health specific exception).
- PA required per policy header: "Yes (always required)".
- Emergency physical health services are exempt from prior authorization: "Prior Authorization is not required for services rendered in emergencies within or outside the service area or network status."
No coding-based step therapy required
There are no coding-based step therapy requirements specified in this policy; coding section is listed as NA.
Document sources used for medical necessity review
Prior authorization and medical necessity reviews rely on specific external guidance sources; providers should cite these when submitting requests.
- Alliance uses NCDHHS CCPs and NCDHHS State-funded service definitions to review prior authorizations for medical necessity.
- When available, MCG Health clinical guidance is used; if none of these sources provide necessary criteria, Alliance CCPs will be used.
- Alliance follows NCDHHS' definition of medical necessity as determined by North Carolina community practice standards.
Denial risk if service not medically necessary or not covered
Requests may be denied when the service is not medically necessary or is not a covered benefit under the member's plan; providers should ensure documentation demonstrates medical necessity and plan coverage.
- Denial trigger: "The requested service must be medically necessary."
- Denial trigger: service must be a covered benefit under the member's applicable plan.
Key Definitions
Policy Background and Clinical References
Alliance bases its coverage and medical necessity determinations primarily on the NCDHHS definition of medical necessity and generally accepted North Carolina community practice standards, verified by independent Medicaid consultants. These sources are supplemented by MCG Health clinical guidance when available; if MCG or NCDHHS criteria are not available for a specific service, Alliance will use its own CCPs to guide decisions. Continuity of care is explicitly recognized as a factor when authorizing out-of-network services.
Policy Revision History
Policy revised to expand applicability to Behavioral Health services in addition to Physical Health services.
Initial approval of the clinical coverage policy (initial effective/review date recorded).
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.