CurrentNorth Dakota Department of Health & Human ServicesPolicy N/A

Out-of-State Services

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This policy governs when North Dakota Medicaid may cover services provided outside North Dakota, including provider enrollment, prior authorization, emergency care, temporary travel, specialized programs, adoption and foster-care assistance, and telehealth.

Policy Summary

PayerNorth Dakota Department of Health & Human Services

PolicyOut-of-State Services

Policy CodePolicy N/A

Change TypeFormat revision and clarification

Effective DateN/A

Next Review DateN/A

Key ActionObtain an out-of-state service authorization for each service or visit, and ensure the service is listed on the authorization letter.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

50 milesOut-of-state service distance threshold

2 weeksAdvance submission for routine requests

48 hoursEmergency transfer notification deadline

Under 21Psychiatric prior-approval age group

Each service/visit

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CurrentNorth Dakota Department of Health & Human ServicesPolicy N/A

Out-of-State Services

Customize your policy alerts

Sign up for all North Dakota Department of Health & Human Services policy alerts

Know when North Dakota Department of Health & Human Services releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerNorth Dakota Department of Health & Human Services

PolicyOut-of-State Services

Policy CodePolicy N/A

Change TypeFormat revision and clarification

Effective DateN/A

Next Review DateN/A

Key ActionObtain an out-of-state service authorization for each service or visit, and ensure the service is listed on the authorization letter.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

50 milesOut-of-state service distance threshold

2 weeksAdvance submission for routine requests

48 hoursEmergency transfer notification deadline

Under 21Psychiatric prior-approval age group

Each service/visit

Authorization frequency

Out-of-State Coverage Criteria

General out-of-state coverage

Out-of-state services must meet all general provider coverage requirements and one qualifying out-of-state circumstance.

General requirements: The provider must be enrolled in ND Medicaid; the service must be medically necessary; the member must be eligible on the date of service; and, if applicable, the service must have approved service authorization.

Qualifying payment circumstance: The service has received service authorization from ND Medicaid; or the health service is provided in response to an emergency while the member is out of state; or the health service is provided to a non-Title IV-E child for whom North Dakota makes a state foster care payment or adoption assistance payment.

Routine out-of-state medical care

Routine out-of-state medical care is covered when all authorization and medical-necessity conditions are met.

Routine medical care criteria: The service is provided more than 50 miles from the North Dakota border; the member's North Dakota primary care provider and/or specialty provider submits a written request at least two weeks before scheduling; the request includes SFN 769 and all required member, diagnosis, service, provider, and clinical information; a written second opinion from an appropriate in-state board-certified specialist supports the request; and the service is not available in North Dakota.More than 50 miles from the North Dakota border; request at least two weeks before appointment scheduling

ND Medicaid determines whether the request meets requirements and issues a written approval or denial.

Emergency and temporary-travel services

Emergency or urgent out-of-state services may be covered under the applicable emergency pathway.

Emergency circumstances: The service is provided in response to an emergency while the member is out of state; or the member is temporarily traveling outside North Dakota and receives urgent or emergency services from an out-of-state provider that enrolls with ND Medicaid and submits supportive medical reports.Emergency transfer notification within 48 hours

Emergency services remain subject to ND Medicaid review for medical necessity.

Traumatic brain injury services

TBI specialized out-of-state placement requires service authorization unless the Minnesota nursing-facility exception applies.

TBI specialized placement: The member requires an out-of-state specialized facility or program for traumatic brain injury; the attending physician provides a letter of medical necessity; complete clinical history and treatment and test results are submitted; past placements and placement dates are listed; and attempts to place the member in state are documented.

A Minnesota nursing facility specializing in TBI does not require an out-of-state referral or approval, but it must obtain a level-of-care determination from ND Medicaid's current contractor.

Out-of-state psychiatric services for children under 21

Out-of-state psychiatric services for children under 21 require prior approval and satisfaction of one in-state-unavailability pathway.

Pediatric psychiatric services: The child is under 21; ND Medicaid grants prior approval; and the referring agency substantiates that treatment options within North Dakota were provided with little to no improvement, the child was denied admission to all available North Dakota facilities, or the out-of-state program is unique and similar services are unavailable in North Dakota.Under 21 years of age

Before admission, the out-of-state facility must complete an admission review with the ND Medicaid contractor to confirm North Dakota Certificate of Need criteria.

Children receiving adoption and foster-care assistance

Special rules apply to children receiving state-funded adoption or foster-care assistance.

Adoption and foster-care assistance pathways: A non-Title IV-E child receiving a North Dakota state-funded adoption subsidy may continue to receive North Dakota Medicaid when the state of residence has not joined the Interstate Compact on Adoption and Medical Assistance or does not give reciprocity; or a child with a federal Title IV-E adoption subsidy or foster-care payment is eligible for Medicaid in the state in which the child resides, including temporary foster-care placements.Generally through age 18, and possibly age 21 when the state of residence offers Medicaid to youth over 18

Out-of-state providers must enroll with ND Medicaid to receive reimbursement for covered services provided to children in foster care.

Telehealth

Telehealth is treated according to the member's location.

Telehealth delivered to a member in North Dakota: The member is located in North Dakota and the telehealth provider is located outside North Dakota but enrolled with ND Medicaid.Member located in North Dakota

The out-of-state service authorization requirement does not apply, but any authorization required for the underlying service must still be obtained before delivery.

Out-of-state service authorization and documentation

Out-of-state care is subject to the following coverage and authorization conditions.

Covered out-of-state service

Location: Care is provided 50 miles or more from the North Dakota border.>= 50 miles from the North Dakota border
Out-of-country care is excluded.
Authorization: An out-of-state service authorization is obtained for each service or visit, and the service is listed on the authorization letter.Each service/visit
Documentation: Current medical documentation supports the need for out-of-state services.
If the service is available in North Dakota, explain why it cannot be performed in North Dakota.

Telehealth services

Telehealth provided to a member located in North Dakota by an ND Medicaid-enrolled out-of-state telehealth provider is treated as in-state care for purposes of the out-of-state service requirement.

Telehealth exception: The member is located in North Dakota and the telehealth provider is enrolled in ND Medicaid as an out-of-state telehealth provider.Member located in ND

Out-of-state service authorization is not required under this policy; authorization remains required if the service itself requires service authorization.

Services received outside the United States are not covered by North Dakota Medicaid. This exclusion applies regardless of whether the care would otherwise meet out-of-state coverage requirements.

An out-of-state provider may receive payment only when the service has ND Medicaid service authorization, is provided in response to an emergency while the member is out of state, or is provided to a non-Title IV-E child for whom North Dakota makes a state foster-care or adoption-assistance payment.

Services that are available in North Dakota are not covered as out-of-state services. Requests for services available in state must explain why the service cannot be performed in North Dakota.

Out-of-country care is not allowed and is excluded from the definition of out-of-state care. Out-of-state care means care provided 50 miles or more from the North Dakota border.

Coverage requires that the service be medically necessary, be a covered ND Medicaid service, and be supported by sufficient current clinical evidence and documentation. Required authorization must be obtained when applicable, and requests must demonstrate the need for out-of-state care; services may be denied or not approved when these requirements are not met.

Authorization, Documentation, and Denial Risks

Billing Rule

Basic Out-of-State Payment Conditions

Before billing an out-of-state service, confirm that the service is medically necessary, the member is eligible on the date of service, and any required service authorization has been approved. The service must be covered by ND Medicaid and rendered by a provider enrolled with ND Medicaid.

Out-of-state providers may receive payment only when the service has ND Medicaid authorization, is provided in response to an emergency while the member is out of state, or is provided to a Non-Title IV-E child for whom North Dakota makes a foster-care or adoption-assistance payment.
Use the Procedure Code Look-up Tool to verify coverage, ORP requirements, service-authorization requirements, and current rates.

Prior Authorization

Prior Approval for Routine Out-of-State Care

Policy Overview

This policy explains when North Dakota Medicaid may cover medically necessary services provided outside North Dakota. In general, coverage depends on the member's eligibility, the provider's ND Medicaid enrollment, the service's coverage status, and required authorization and documentation. Routine care generally requires evidence that the service is unavailable in North Dakota, while emergency, temporary-travel, specialized traumatic brain injury, pediatric psychiatric, foster-care or adoption-assistance, and telehealth services follow specific coverage pathways. Out-of-state care is defined as care provided 50 miles or more from the North Dakota border; care received outside the United States is excluded.

Key Terms

Out-of-state services

DefinitionCare or services rendered by a provider located more than 50 miles outside of North Dakota.

Provider typeThe provider may be an individual or a facility.

Geographic exclusionThe provider may not be located outside the United States.

Out-of-state provider

DefinitionAn individual or facility provider located 50 miles or more outside of North Dakota.

EnrollmentThe provider must be enrolled with ND Medicaid on the date of service to receive payment.

Covered role

Policy Summary

PayerNorth Dakota Department of Health & Human Services

PolicyOut-of-State Services

Policy CodePolicy N/A

Change TypeFormat revision and clarification

Effective DateN/A

Next Review DateN/A

Key ActionObtain an out-of-state service authorization for each service or visit, and ensure the service is listed on the authorization letter.

SourceLink

On This Page

Obtain prior approval for routine out-of-state medical services provided more than 50 miles from the North Dakota border. The member’s North Dakota primary care and/or specialty provider must submit a written request for authorization for each service at least two weeks before scheduling the appointment.

ND Medicaid reviews the request and issues a written approval or denial to the requesting in-state provider(s), member, out-of-state provider(s), and human service zone office.

Prior Authorization

TBI Specialized Placement Authorization

Out-of-state services in a specialized facility or program for a member with a traumatic brain injury require service authorization, unless the Minnesota nursing-facility exception applies. If approved, ND Medicaid sends an approval notice.

A Minnesota nursing facility specializing in TBI services does not need an out-of-state referral or approval, but the admitting facility must obtain a level-of-care determination from ND Medicaid’s current contractor.
The exception applies to the specified Minnesota TBI nursing-facility placement; follow the Nursing Facilities policy for level-of-care procedures and screening forms.

Prior Authorization

Pediatric Psychiatric Prior Approval

Obtain ND Medicaid prior approval for out-of-state psychiatric services for children under 21 before admission. After approval and before admission, the out-of-state facility must complete an admission review with the ND Medicaid contractor to confirm that the child’s care and conditions meet North Dakota Certificate of Need criteria.

The referring North Dakota agency must ensure appropriate in-state services are unavailable and support that in-state treatment produced little or no improvement, all available North Dakota facilities denied admission, or the out-of-state program is unique.

Prior Authorization

Emergency Services Retrospective Review

Emergency out-of-state services may be provided at the in-state physician’s discretion, but they remain subject to ND Medicaid review. The transferring facility must notify ND Medicaid within 48 hours of the transfer.

Provide medical evidence supporting the need for air ambulance whenever air ambulance transportation is used.

Unsupported block type: prior_auth>

Prior Authorization

Telehealth Authorization Rule

Telehealth delivered to a member located in North Dakota by an out-of-state provider enrolled with ND Medicaid is not considered out-of-state care, so an out-of-state service authorization request is not required. However, obtain authorization before rendering the service when the telehealth service itself requires service authorization.

Confirm the provider is enrolled with ND Medicaid and the member is located in North Dakota at the time of service.

Documentation Required

Routine Out-of-State Medical Request Documentation

For routine out-of-state medical care more than 50 miles from the North Dakota border, submit SFN 769 at least two weeks before the appointment with complete clinical and referral information. ND Medicaid also requires current supporting medical information, a qualified in-state second opinion, and assurance that the service is unavailable in North Dakota.

Member name, date of birth, and Medicaid number.
Diagnosis, reason for out-of-state care, requested service date if known, and requested service(s).
In-state primary care provider and/or specialist, and the referred out-of-state practitioner and/or facility.
Current medical information must generally be within three months.
Include a written second opinion from an appropriate in-state board-certified specialist and assurance that the service is not available in North Dakota.

Documentation Required

Emergency Transfer Documentation

For an emergency transfer, submit a completed SFN 769 and supporting transfer documentation for ND Medicaid review. The transferring facility must notify ND Medicaid within 48 hours.

Date of transfer.
Mode of transportation.
Medical documentation, including the discharge summary.
Medical evidence supporting the need for air ambulance when air ambulance is used.

Documentation Required

Travel-Related Emergency Records

When a member receives emergent medical or surgical care while traveling outside North Dakota, the out-of-state facility must submit the admission history and physical and discharge summary to ND Medicaid. These records are reviewed to determine medical necessity.

Submit the records for emergent care received while the member is traveling, even when the care was not a planned out-of-state referral.

Documentation Required

TBI Placement Documentation

Support a TBI specialized out-of-state placement request with complete clinical and placement documentation so ND Medicaid can determine whether the placement is appropriate and medically necessary.

Letter of medical necessity from the attending physician.
Complete clinical history, treatment information, and test results.
Listing of past placements and placement dates.
Information regarding attempts to place the member in state.

Documentation Required

Pediatric Psychiatric Service Documentation

A North Dakota agency requesting out-of-state psychiatric services for a child under 21 must substantiate that appropriate in-state services are unavailable. Document the child’s prior in-state treatment and limited improvement or the lack of an available appropriate facility.

Document treatment options provided in North Dakota, such as outpatient, acute inpatient, or residential treatment, with little to no improvement in the child’s behavioral disorder.
Document denial of admission by all available North Dakota facilities, or explain why the out-of-state program is unique and has no similar in-state service.

Documentation Required

Temporary Travel Emergency Documentation

For urgent or emergency services provided to a member temporarily traveling outside North Dakota, the out-of-state provider must enroll as a ND Medicaid provider and submit supportive medical reports. Refer to the Out-of-State Provider section of the Provider Enrollment policy.

This rule applies to qualifying urgent or emergency services while the member is temporarily outside the state.

Documentation Required

Records Retention and Completeness

Maintain legible medical and financial records that fully justify and disclose the extent of services provided and billed to ND Medicaid. Retain records for at least seven years after the last date the claim was paid or denied and follow the Provider Requirements Policy.

Records must be complete and legible enough to support the services billed.
Apply the seven-year retention period after the last claim payment or denial.

Documentation Required

Support Out-of-State Medical Necessity

Include current clinical documentation supporting the need for out-of-state services in every authorization request. When the specialty service is available in North Dakota, explain why it cannot be performed in state.

Ensure the medical-necessity documentation is current and directly supports the requested out-of-state service.

Denial Risk

Failure to Meet General Coverage Requirements

Claims may be denied when general coverage requirements are not met. Confirm member eligibility, covered-service status, medical necessity, provider enrollment, and any applicable authorization before rendering and billing the service.

The member must be eligible on the date of service.
The service must be medically necessary and covered by ND Medicaid.
The provider must be enrolled with ND Medicaid, and required service authorization must be approved.

Denial Risk

Insufficient Prior Authorization Request

A routine out-of-state request may be denied when it is submitted late, lacks required clinical information, or omits the required in-state specialist second opinion. Submit the request at least two weeks before scheduling and provide all required support.

Include current medical information, generally within three months.
Include a written second opinion from an appropriate in-state board-certified specialist.
Include assurance that the requested service is not available in North Dakota.

Denial Risk

In-State Psychiatric Alternatives Available

Out-of-state psychiatric services for a child under 21 may be denied when the referring agency does not establish that appropriate in-state services are unavailable. Document the relevant in-state treatment history, facility denials, or the unique nature of the proposed program.

Do not request approval without evidence that available North Dakota treatment options were ineffective, all available facilities denied admission, or the out-of-state program has no comparable in-state alternative.

Denial Risk

Insufficient TBI Placement Documentation

A TBI placement request may be denied when medical necessity is unsupported or the clinical and placement materials are incomplete. Provide the attending physician’s medical-necessity letter, complete clinical history, treatment and test results, past placement history, and evidence of attempts to place the member in state.

ND Medicaid reviews the referral information to determine whether out-of-state placement is appropriate and medically necessary.

Denial Risk

Noncovered Out-of-State or Out-of-Country Care

North Dakota Medicaid does not cover services received outside the United States. Out-of-state care may also be noncovered when the service is available in North Dakota, subject to applicable policy requirements and authorization rules.

Confirm that an appropriate service is not available in North Dakota before pursuing covered out-of-state care.
Do not submit claims for services received outside the United States.

Denial Risk

Missing or Incomplete Service Authorization

Each out-of-state service or visit must be authorized and listed on the service authorization letter. Missing or incomplete authorization for a service may result in denial of the related claim.

Review the authorization letter before billing to confirm that every service or visit is identified.

When approved, the provider may furnish covered out-of-state services.

Telehealth out-of-state provider service

DefinitionA service provided to a member while the member is located in North Dakota by an ND Medicaid-enrolled provider located outside North Dakota.

Out-of-state classificationThe service is not considered out-of-state care under this policy.

AuthorizationOut-of-state service authorization is not required, but authorization is still required if the service itself requires it.

Emergency out-of-state service

DefinitionA service provided in response to an emergency while a member is out of state.

ReviewThe service remains subject to ND Medicaid review.

DocumentationApplicable documentation requirements must be satisfied.

Out-of-State Care

DefinitionCare provided 50 miles or more from the North Dakota border.

Distance thresholdThe threshold is 50 miles or more from the North Dakota border.

ExclusionOut-of-country care is not included.