Limitations on out-of-state care

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.