Out of Network Services
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Governs Meridian Health Plan of Michigan coverage and criteria for services rendered by providers who are not part of Meridian's contracted network, including transition and continuity of care provisions and exceptions to prior authorization requirements.
No material clinical or coverage changes in this revision.
Out-of-Network Coverage Criteria
Out of Network: Section A - General criteria
Covered when ALL of the following are met:
Represented as an AND group with an embedded OR for item vi.
Out of State/Out of Network
Out of State/Out of Network coverage conditions:
All Out of State reimbursements require Section A plus at least one listed condition.
Transition and Continuity of Care
Transition and continuity of care requirements:
TOC protections and minimum timeframes apply as listed.
COC is limited to defined clinical severity categories and requires medical necessity review.
Out of Network Exceptions (no prior authorization required)
Exceptions that do not require prior authorization regardless of network status:
Items listed correspond to policy items i through x.
Out of Country Services (not covered)
Explicit exclusion for out-of-country services.
Mental Health Services
Limits Meridian responsibility to outpatient mental health services only.
General Coverage Governance
Covered when consistent with plan terms and applicable law:
Medicaid and Medicare provisions take precedence where applicable
Requests for items or services located outside of the United States are not a covered benefit. This exclusion is supported by Federal Regulation 42 USC 1396a and applies to any services physically performed or billed from providers located outside the U.S.
This clinical policy is intended as a guide to medical necessity and to assist in coverage decision-making; it does not constitute a contract, guarantee of payment, or guarantee of clinical outcomes. Coverage determinations remain subject to all terms, conditions, exclusions, and limitations of the member’s coverage documents and applicable state and federal law.
No explicit additional coverage exclusions are listed in the provided appendix text. The appendices included in this policy present county-level CMS Health Delivery Table categorizations (Appendix B) and Timely Access Standards (Appendix C) rather than specific coverage exclusions; they serve as reference material for time/distance, county designations, and appointment target timeframes.
Continuity of care provisions do not apply to elective procedures, minor illness, or a non‑acute, well‑managed chronic disease. Continuity of care is limited to members in an active course of treatment for life‑threatening, serious acute, or complex medical conditions (including postoperative care).
The policy provides a medical necessity guide to support coverage decisions and reviews; it is not a standalone definition of every not‑medically‑necessary condition. Meridian will perform medical necessity reviews consistent with generally accepted standards of medical practice and the criteria described elsewhere in the policy.
Within the provided appendix content there are no discrete lists of not‑medically‑necessary (NMN) conditions. Appendix materials reference county classifications and timely access targets but do not specify NMN services in these chunks.
Coding References
| No codes listed |
| No codes listed |
Provider Requirements, Prior Authorization, and Denial Triggers
Prior authorization required for non-emergency out-of-state services
Non-emergency out-of-state or out-of-network services require prior authorization. Meridian will only prior authorize non-emergency out-of-state services when the service is not available within the state of Michigan, and reimbursement requires the service also meet all Section A out-of-network criteria.
- Prior authorization is required for non-emergency out-of-state/out-of-network services.
- Meridian will only prior authorize these services if the service is not available within Michigan.
- All Section A out-of-network criteria must be met for reimbursement.
Prior authorization governed by member coverage documents
Prior authorization requirements and coverage determinations are governed by the member's coverage documents and Health Plan-level administrative policies; apply the terms, conditions, exclusions and limitations in the member's coverage documents when determining prior authorization necessity.
- Coverage and prior authorization are subject to the member's evidence of coverage/policy terms and applicable administrative procedures.
- State Medicaid provisions or Medicare NCDs/LCDs take precedence where applicable and should be reviewed.
No specific prior authorization rules stated here
These sections do not specify procedure- or code-level prior authorization rules; they provide timely access appointment targets and high-level guidance instead.
- Timely access targets (e.g., urgent care within 48 hours; routine care within 30 business days) are listed but are not stated as prior authorization criteria.
Honor prior payer authorizations; medical necessity reviews permitted
Meridian must honor prior authorizations issued by a prior payer for the timeframe specified and may conduct medical necessity reviews consistent with generally accepted standards when members' needs change.
- Meridian will honor prior payer authorizations for the timeframe specified and may review medical necessity if care changes.
- Medical necessity reviews must reflect generally accepted standards and appropriateness of type, frequency, extent, duration and setting.
Transition of care timeframes — 90-day minimums
During transition of care, Meridian must maintain current providers and levels of services for at least 90 days from enrollment and must honor existing prior authorizations for at least 90 days.
- Maintain current providers and service levels for a minimum of 90 days from enrollment.
- Honor existing prior authorizations for at least 90 days from enrollment.
Step therapy not specified
No step therapy requirements are described in these sections.
- Step therapy is not addressed in the provided chunks.
Provider licensing, certification, and payment acceptance
Out-of-network providers must be licensed/certified by the appropriate authority and must agree to accept payment based on the contracted state's Medicaid fee screen; services must be medically necessary and benefit eligible.
- Provider must be licensed and/or certified by the appropriate standard-setting authority.
- Provider must agree to accept payment based on the contracted state's Medicaid fee screen.
- Requested services must be medically necessary and benefit eligible.
Providers bound by contract or by submitting claims
Providers are bound by the terms of their contracts or by providing services/submitting claims; state Medicaid provisions and Medicare NCDs/LCDs take precedence where applicable and should be reviewed.
- Providers are bound to terms through contracts, or by providing services/submitting claims agree to be bound by those terms.
- Medicaid state provisions and Medicare coverage determinations take precedence when applicable.
Required reference materials: Appendix B and C
Refer to Appendix B (CMS Health Delivery Table) and Appendix C (Timely Access Standards) for county-level delivery designations and appointment wait-time targets used in network adequacy and access assessments.
- Appendix B lists county-level CMS Health Delivery Table categorizations (e.g., Rural, Micro).
- Appendix C lists Timely Access Standards (e.g., urgent care within 48 hours; routine care within 30 business days).
Denial triggers when Section A criteria are not met
A request may be denied if the request fails to meet all Section A criteria — for example, if the service is not benefit eligible, not medically necessary, available in-network, or the provider is not licensed/certified or will not accept payment per the Medicaid fee screen.
- Denial triggers include services that are not benefit eligible or not medically necessary.
- Denial triggers include services available in-network or providers who are not licensed/certified or who refuse payment per the Medicaid fee screen.
Coverage decisions subject to coverage document terms and legal requirements
Coverage decisions are subject to all terms, conditions, exclusions and limitations of the member's coverage documents and applicable state and federal requirements; these govern application of the policy.
- Apply the member's evidence of coverage, policy, and relevant state/federal requirements when adjudicating claims.
- This clinical policy does not guarantee payment; contractual and legal provisions prevail.
No additional denial triggers specified
These chunks do not list explicit denial triggers beyond Section A; timely access standards are operational access targets and are not stated as denial criteria.
- Timely access metrics are provided for operational use but are not defined here as reasons to deny coverage.
Background and Policy Scope
Continuity of Care applies to members in an active course of treatment for life‑threatening, serious acute, or complex medical conditions, and includes postoperative care. Meridian will review such cases for medical necessity using the policy’s stated standards and may apply time/distance and network adequacy considerations from the appendices when implementing continuity provisions.
Key Definitions
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