210-RICR-20-00-3. Medicaid Payments for Out-of-State Care (version Technical Revision, 04/03/2006 to 03/16/2018)

0314 MA PAYMENT FOR OUT OF STATE CARE 0314.05 REQUIREMENT OF PRIOR AUTHORIZATION REV:01/2002 Payment for out-of-state medical services that are provided to eligible MA recipients living within Rhode Island requires PRIOR AUTHORIZATION from the Division of Medical Services. The following conditions must be met to obtain prior authorization for out-of-state medical services: o If a patient requires services from an out-of-state hospital or physician, the patient's attending physician must submit written medical justification to the Division of Health Care Quality, Financing and Purchasing; o The service which is required and being requested must not be available within Rhode Island. Recipients who inquire about out-of-state medical services are informed that prior authorization is required, and that only those services within Rhode Island MA scope of services will be recognized. 0314.05.05 Exceptions to the Requirement of Prior Auth REV:06/1994 The following provisions are exceptions to the requirement for prior authorization: o Emergency medical treatment and hospital services were needed because the recipient's health would have been endangered if required to travel back to Rhode Island; o Treatment was provided by hospitals and practitioners located in close proximity to the Rhode Island state line(e.g., Attleboro, Seekonk, Fall River, New London, etc.) where it is the general practice for residents to use medical resources outside the State; o Medical and hospital treatment were provided to foster children residing with families located outside Rhode Island or in out-of-state residential treatment centers. 0314.05.10 Services Rendered to Temp Absent Recipients REV:06/1994 Payment for medical care provided to eligible residents of Rhode Island who are temporarily absent from the state is made under certain circumstances. Temporarily absent includes visiting, traveling or residing temporarily in another state without intending to become a permanent resident of the other state. MA payment is authorized only in one of the following circumstances: o An emergency arises from accident or illness; or o The health of the individual would be endangered if the care and services were postponed until the individual returned to Rhode Island; or o The health of the individual would be endangered if s/he undertook travel to return to Rhode Island. 0314.05.15 Follow-up Procedures REV:01/2002 When bills are received over a continuing period of time for out-of-state medical care not previously authorized, and which was rendered to MA recipients temporarily absent from the state, the following occurs: o The Division of Health Care Quality, Financing and Purchasing notifies the district office that follow-up is needed; o The district office mails form AP-719 to the recipient at the out-of-state address; o If the recipient indicates s/he is planning to return to the state, written notification of this effect is sent to the Division of Medical Services; o If the recipient indicates s/he plans to reside permanently outside the state, the case is closed at the end of the month following the month of notification of intent to reside outside Rhode Island.