Thursday, May 23, 2019

Does out of state patient eligible for coverage ?


COVERAGE OUT OF STATE



A member, who is temporarily out of the state but still a resident of Arizona, is entitled to receive AHCCCS benefits under any of the following conditions:

1. Medical services are required because of a medical emergency. Documentation of the emergency must be submitted with the claim to AHCCCS.

2. The member requires a particular treatment that can only be obtained in another state.

3. The member has a chronic illness necessitating treatment during a temporary absence from the state or the member’s condition must be stabilized before returning to the state. Services furnished to AHCCCS members outside of the United States are not covered.


 GENERAL QUESTIONS

* We have patients that come from other states and have Medicaid from other states. How do we handle this?


Florida Medicaid cannot be billed for Medicaid recipients from other states.  Each state’s Medicaid program operates independently essentially 50 separate programs).Florida Medicaid  beneficiaries are covered for emergency care or prior approved care in other states. You would have to contact the other state’s Medicaid program to find out if they have a similar provision for their beneficiaries who need out-of-state care.

TRANSPORTATION REQUIRING PRIOR APPROVAL

Non-Emergency Medical Transportation (NEMT)


- All requests for out-of-state transportation and certain related expenses must have prior approval from the broker, except for travel to those facilities which have been granted in-network status. Facilities granted innetwork status are considered in-state providers. Members are required to contact the broker to schedule the travel for all medical appointments or visits, regardless of the in-network or out-of-network status.

NOTE: Individuals who receive both Medicare and Medicaid do not require prior approval for out-of-state transportation


Hospital - An entity that is licensed as an acute care hospital in accordance with applicable state laws and regulations, or the applicable state laws and regulations of the state in which the entity is located when the entity is out-of-state, and is certified under Title XVIII of the federal Social Security Act. The term “hospital” includes a Medicare- or state-certified distinct rehabilitation unit, a “psychiatric hospital” as defined in this section, or any other distinct unit of the hospital. (WAC 182-550-1050)


Out-of-state hospital admissions (does not include hospitals in designated bordering cities)


The agency pays for emergency care at an out-of-state hospital for Medicaid and CHIP clients only.

Note: The agency considers hospitals in designated bordering cities, listed in WAC 182-501-0175, as in-state hospitals for coverage and as out-of-state hospitals for payment, except for critical border hospitals. The agency considers critical border hospitals “in-state” for both coverage and payment.

The agency requires PA for elective, non-emergency care. Providers should request PA when:

• The client is on a medical program that pays for out-of-state coverage. Example: Aged, Blind, Disabled (ABD) Assistance (formerly Disability Lifeline clients) have no out-ofstate benefit except in designated bordering cities.




ELIGIBILITY EFFECTIVE DATES

The following general guidelines apply to eligibility effective dates:

1. For most members, eligibility is effective from the first day of the month of application, the first day of the month in which the member meets the qualifications for the program, or their date of birth, whichever is later.

2. For KidsCare members, if the eligibility determination is completed by the 25th day of the month, eligibility begins on the first day of the following month. For eligibility determinations completed after the 25th day of the month, eligibility begins on the first day of the second month following the determination of eligibility.

3. For Medicare Savings Program (MSP) – QMB members, eligibility begins with the month following the month that QMB eligibility is determined.

4. For Breast and Cervical Cancer Treatment Program (BCCTP) members, eligibility begins on the later of the first date of the month (the application month for BCCTP is the month of the BCCTP diagnosis), or the first day of the month in which the customer meets all the BCCCTP eligibility requirements.

5. For a move into state or release from prison, the begin date is no sooner than that date.

No comments:

Post a Comment

Most read cpt modifiers