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    v1.0.28
    OpenPayerPolicy UpdatesAdministrative/Operational PolicyIndiana Medicaid Out-of-State PA Policy | OpenPaye…
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    CurrentIndiana Department of InsurancePolicy PROMOD00011

    Out-of-State Providers

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    This policy governs Indiana Health Coverage Programs fee-for-service services furnished by providers located outside Indiana, including enrollment, in-state status, prior authorization, service restrictions, and reimbursement.

    Policy Summary
    PayerIndiana Department of Insurance
    PolicyOut-of-State Providers
    Policy CodePolicy PROMOD00011
    Change TypeScheduled administrative update
    Effective DateDecember 1, 2025
    Next Review DateN/A
    Key ActionEnroll in IHCP before seeking reimbursement for services provided to IHCP members.
    SourceLink
    POLICY UPDATE CHANGES

    Version 8.0 was issued as a scheduled administrative update that clarified text, added Indiana PathWays to the managed-care note, and updated the out-of-state medical equipment supplier note.

    1 day–1 yearPossible prior-authorization period
    70%Minimum Indiana DME/HME business
    130%Enhanced children's hospital rate
    Under 19Enhanced reimbursement age limit
    2

    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.

    Excluded long-term care categories
    12Eligible children's hospitals

    Out-of-State Coverage and Authorization Criteria

    Criteria for PA of covered out-of-state medical services

    Covered out-of-state services may receive prior authorization when medically necessary and at least one additional qualifying condition is satisfied.

    ALL of the following

    • ALL of the following

      • The service is medically necessary.

      • ONE of the following

        • The service is not available in Indiana, except out-of-state Veterans Administration care is exempt from this availability requirement.
        • The member previously received services from the provider.
        • Transportation to an appropriate Indiana facility would cause undue expense or hardship to the member or IHCP.
        • The out-of-state provider is a regional treatment center or distributor.
        • The out-of-state provider is significantly less expensive than Indiana providers.

    Exceptions to additional out-of-state PA

    Additional out-of-state prior authorization requirements are waived when the provider or service qualifies for one of the following exceptions or the provider has approved in-state status.

    ONE of the following

    • The service is an emergency; although prior authorization is not required initially, continuation of inpatient treatment or hospitalization requires prior authorization within 48 hours of admission.
    • The service is a pharmacy service.
    • The service is telehealth and the provider has the Telemedicine enrollment subtype.
    • The provider has in-state status because its service location is in a designated out-of-state county.
    • The provider has in-state status because it meets at least one listed special circumstance.

    Out-of-state service exclusions

    The following services are not eligible for prior authorization and are not covered when provided outside Indiana by any out-of-state provider, including providers designated as in-state for PA purposes.

    ANY of the following

    • Services provided by a home health agency, nursing facility, or intermediate care facility for individuals with intellectual disabilities (ICF/IID).
    • Services provided by any other type of long-term care facility, including a facility directly associated with or part of an acute care general hospital, unless otherwise approved by Indiana FSSA.

    Codes, Rates, and Authorization Limits

    FFS identification code for enhanced children's hospital reimbursementModifierCovered
    9046Out of State Children's Hospital additional payment
    Outpatient revenue codes excluded from children's hospital enhancementRevenueNot Covered
    274Revenue code for prosthetic/orthotic device details excluded from the children's hospital enhanced outpatient rate
    636Revenue code for drug details excluded from the children's hospital enhanced outpatient rate
    Provider types and specialties referenced for out-of-state enrollment and facility reimbursementmixed
    01Hospital provider type
    010Acute care hospital specialty
    011Psychiatric hospital specialty
    012Rehabilitation hospital specialty
    02Ambulatory surgical center provider type
    020Ambulatory surgical center specialty
    11Outpatient mental health clinic provider type
    110Outpatient mental health clinic specialty
    25DME/HME and medical supply dealer provider type
    30ESRD freestanding renal dialysis clinic provider type
    1–10 of 11
    1/2
    Prior Authorization Period
    Maximum authorization period1 year
    Available authorization rangeOne day to one year
    Authorization conditionsThe service must be medically necessary and meet at least one qualifying out-of-state service criterion
    Emergency Inpatient PA
    Initial emergency-service PANot required
    Continuation-of-care deadlineWithin 48 hours of admission

    Required Provider Actions

    Documentation Required

    Enroll before seeking reimbursement

    Enroll in the Indiana Health Coverage Programs (IHCP) before seeking reimbursement for services provided to IHCP members. Out-of-state providers must meet the applicable out-of-state enrollment documentation requirements; eligible providers may also enroll under the ordering, prescribing or referring provider type.

    Prior Authorization

    Request PA for out-of-state services

    Obtain prior authorization (PA) for covered out-of-state services unless an exception applies. PA may be granted for any period from one day to one year when the service is medically necessary and at least one additional qualifying criterion is met.

    • The service is not available in Indiana, except out-of-state Veterans Administration care.
    • The member previously received services from the provider.
    • Transportation to an appropriate Indiana facility would cause undue expense or hardship.

    Key Policy Definitions

    In-State Status
    DefinitionAn enrollment designation for an eligible provider located outside Indiana
    PA effectAllows the provider to follow regular in-state PA guidelines instead of the additional out-of-state PA requirements
    Continuing requirementThe provider must still meet out-of-state documentation requirements for IHCP enrollment
    Out-of-State Areas Designated as In-State
    Geographic designationCertain out-of-state counties are treated as in-state for IHCP prior authorization purposes
    Qualifying areasCounties in the metropolitan statistical areas of major cities within or bordering Indiana
    Policy Summary
    PayerIndiana Department of Insurance
    PolicyOut-of-State Providers
    Policy CodePolicy PROMOD00011
    Change TypeScheduled administrative update
    Effective DateDecember 1, 2025
    Next Review DateN/A
    Key ActionEnroll in IHCP before seeking reimbursement for services provided to IHCP members.
    SourceLink
    On This Page
    Out-of-State Coverage and Authorization CriteriaCodes, Rates, and Authorization LimitsRequired Provider ActionsKey Policy Definitions
  1. The provider is an out-of-state DME/HME or medical supply dealer (provider type 25) with an Indiana business office and meets all applicable in-state-status requirements.
    2. Applies to
    Emergency care that continues as inpatient treatment or hospitalization
    DME/HME In-State Status
    Applicable provider typeProvider type 25 DME/HME and medical supply dealers
    Indiana business requirementMaintain an Indiana business office staffed during regular business hours with telephone service
    Indiana business percentageAnticipate at least 70% of Indiana business through mail-order or online purchases
    DocumentationSubmit supporting documentation for each asserted circumstance at enrollment
    Children’s Hospital Enhanced Reimbursement
    Member age requirementMember younger than 19 years
    Services covered by enhancementEligible inpatient and outpatient services provided by qualifying out-of-state children’s hospitals
    Initial approved periodJuly 1, 2021, through June 30, 2025
    Enhanced Reimbursement Rate
    When no Medicare rate exists130% of the standard IHCP Medicaid rate
    When a Medicare rate existsA rate comparable to the current federal Medicare reimbursement rate for the service
    Eligible providersQualifying out-of-state children’s hospitals
    Enhanced Reimbursement Extension
    Extended expiration dateJuly 1, 2027
    Approval conditionPending approval from the Centers for Medicare & Medicaid Services (CMS)
    Original expiration dateJune 30, 2025
  2. The provider is a regional treatment center or distributor.
  3. The provider is significantly less expensive than Indiana providers.
    4. Prior Authorization

    Apply PA exceptions

    Use the regular in-state PA requirements instead of the additional out-of-state PA requirement when an exception applies. Exceptions include emergency services, pharmacy services, telehealth provided by an enrolled provider with the Telemedicine subtype, and services from a provider with approved in-state status.

    Prior Authorization

    Submit continuation-of-care PA

    Although emergency services do not require PA initially, request PA within 48 hours of admission when emergency care continues as inpatient treatment or hospitalization.

    Prior Authorization

    Handle Adoption Assistance Program members

    For Adoption Assistance Program members placed outside Indiana, submit PA for routine out-of-state medical and dental care. The out-of-state PA requirement is not waived, but IHCP will approve all such PA requests.

    Prior Authorization

    Request in-state status

    Request in-state status during IHCP enrollment, revalidation, or an update to an existing enrollment when eligible. Approved in-state status removes the additional out-of-state PA requirements, but out-of-state enrollment documentation and provider eligibility requirements still apply.

    • A service location may be in a designated out-of-state county.
    • The provider may meet a listed special circumstance.
    • A qualifying provider type 25 DME/HME supplier may meet the applicable supplier requirements.
    Documentation Required

    Support special-circumstance status

    Support a request for in-state status with documentation of at least one qualifying circumstance. The circumstance must show how enrollment improves access, preserves needed primary or specialty care, avoids significant transportation expense or hardship, or addresses an emergency health crisis.

    • Improving access where distance creates significant financial hardship or an unnecessary significant burden.
    • Allowing a member to retain a primary provider or obtain unavailable or geographically burdensome specialty care.
    • Avoiding significant transportation expense or hardship.
    • Addressing an emergency health crisis.
    Documentation Required

    Meet DME/HME in-state-status requirements

    Provider type 25 DME/HME suppliers outside Indiana and designated areas must meet all listed requirements to request in-state PA status and submit supporting documentation for each asserted circumstance.

    • Maintain an Indiana business office staffed during regular business hours with telephone service.
    • Provide service, maintenance, and replacements for IHCP members whose equipment has malfunctioned.
    • Qualify with the Indiana Secretary of State as a foreign corporation.
    • Anticipate at least 70% of Indiana business through mail order or online purchases.
    Prior Authorization

    Follow DME/HME PA rules

    Follow the PA requirements in the Durable and Home Medical Equipment and Supplies module for every PA request submitted by a DME or HME supplier.

    Denial Risk

    Avoid noneligible out-of-state services

    Do not submit PA for, or expect coverage of, services provided outside Indiana by home health agencies, nursing facilities, ICFs/IID, or other long-term care facilities, including facilities directly associated with or part of an acute care general hospital, unless otherwise approved by Indiana FSSA.

    Complete location list
    The complete applicable ZIP-code list is provided in the Out-of-State Areas Designated as In-State for IHCP Providers spreadsheet
    Eligible Out-of-State Children’s Hospital
    Location requirementThe hospital must be located in a state bordering Indiana
    Facility requirementThe hospital must be a freestanding general acute care hospital or a facility within a freestanding general acute care hospital
    Qualifying hospital criterionIt must be designated by Medicare as a children’s hospital or predominantly furnish inpatient and outpatient healthcare services to patients younger than 19