North Dakota Administrative Code
Title 75 - Department of Human Services
Article 75-02 - Economic Assistance
Chapter 75-02-02 - Medical Services
Section 75-02-02-13 - Limitations on out-of-state care
Universal Citation: ND Admin Code ยง 75-02-02-13
Current through Supplement No. 394, October, 2024
1. For purposes of this section:
a. "Out-of-state
care" means care or services furnished by any individual, entity, or facility,
pursuant to a provider agreement with the department, at a site located more
than fifty statute miles [80.45 kilometers] from the nearest North Dakota
border.
b. "Out-of-state provider"
means a provider of care or services that is located more than fifty statute
miles [80.45 kilometers] outside of North Dakota. An out-of-state provider may
be an individual or a facility but may not be located outside of the United
States.
c. "Specialist" means a
physician board certified in the required medical specialty who regularly
practices within North Dakota or at a site within fifty statute miles [80.45
kilometers] from the nearest North Dakota border.
2. Except as provided in subsection 3, no payment for out-of-state care, including related travel expenses, will be made unless:
a. The recipient was first seen by
that recipient's enrolled in-state provider;
b. The enrolled in-state provider determines
that it is advisable to refer the recipient for care or services which the
enrolled in-state provider is unable to render and a referral is made to an
in-state, board-certified physician specialist, if available;
c. Recipient is evaluated by a
board-certified physician specialist;
d. The physician specialist concludes that
the recipient should be referred to an appropriate out-of-state provider
because necessary care or services are unavailable in the state;
e. The enrolled in-state provider or
in-state, board-certified physician specialist submits, to the department, a
written request that includes medical and other pertinent information,
including the report of the specialist that documents the specialist's
conclusion that the out-of-state referral is medically necessary;
f. The department determines that the
medically necessary care and services are unavailable in the state and approves
the referral on that basis; and
g.
The claim for payment is otherwise allowable and verifies that the department
approved the referral for out-of-state care.
3.
a. A
referral for emergency care, including related travel expenses, to an
out-of-state provider can be made by the enrolled in-state provider. A
determination that the emergency requires out-of-state care may be made at the
enrolled in-state provider's discretion, but is subject to review by the
department. Claims for payment for such emergency services must identify the
referring enrolled in-state provider and document the emergency.
b. Claims for payment for care for a medical
emergency or surgical emergency, as those terms are defined in section
75-02-02-12, which occurs when the
affected recipient is traveling outside of North Dakota, will be paid unless
payment is denied pursuant to limitations contained in section
75-02-02-12.
c. Claims for payment for any covered service
rendered to a recipient who is a resident of North Dakota for Medicaid and
children's health insurance program purposes, but whose current place of abode
is outside of North Dakota, will not be governed by this section.
d. Claims for payment for any covered service
rendered to a recipient during a verified retroactive eligibility period will
not be governed by this section.
e.
If a recipient is referred for out-of-state care without first securing
approval under subsection 2, and the care is not otherwise allowable under this
subsection, the department may approve payment upon receipt of a written
request, from the enrolled in-state provider or specialist, that:
(1) Demonstrates good cause for not first
securing approval under subsection 2;
(2) Clearly establishes that the care and
services were unavailable in the state; and
(3) Documents that the care and services were
medically necessary.
4. An out-of-state provider who does not maintain a physical, in-state location or a location within fifty statute miles [80.45 kilometers] of North Dakota will not be enrolled as a Medicaid provider unless the department determines the provider's enrollment is necessary to ensure access to covered services.
General Authority: NDCC 50-24.1-04
Law Implemented: NDCC 50-24.1-02
Disclaimer: These regulations may not be the most recent version. North Dakota may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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