Family and Children's Medicaid MA-3335 STATE RESIDENCE
VII. MEDICAL CARE PROVIDED OUTSIDE OF NC
A. Medical care and services provided outside of NC to residents of NC who are Medicaid eligible in private living situations are covered:
1. Without prior approval:
a. Residents of a border county who customarily use providers across the state line, other than placement in a nursing facility. This may be a general practice for residents to use medical resources outside of NC.
b. In the event of an accident or the need for emergency medical care arises in another state. The out-of-state provider of the medical service must document that:
(1) The medical care was provided as the result of an emergency arising from an accident or illness, or
(2) The person’s health would be endangered if he undertook travel to return to NC.
2. In cases requiring prior approval, the Division of Medical Assistance determines that the needed medical service or necessary supplementary resources are more readily available in the other state or cannot be reasonably provided in NC.
3. Long-term care services in a nursing facility in another state are covered by NC Medicaid if:
a. The individual was placed by a NC agency, including a dss, or
b. The individual is temporarily absent from NC and has been granted prior approval by NC Medicaid for coverage of the medical care in the other state, or
c. The Division of Medical Assistance has granted prior approval for specialized care that is not available in NC.
B. Inform the a/b that:
1. Claims may not be paid outside of NC except for the reasons stated in A. above, and
REISSUED 08/01/13 – CHANGE NO. 04-13
2. The provider must enroll in and agree to accept payment from the NC Medicaid program if he has rendered a service that NC Medicaid can cover.
C. Questions about Medicaid Claims and State Residence
The Claims Analysis Unit at DMA routinely reviews claims for care provided out-of-state. If the review indicates that an active beneficiary claims an address in another state, they will send a letter to the county department of social services advising them of this. They will not send the letter if the beneficiary’s case in NC has been terminated. Also, since foster children can be placed out-of-state and retain NC residence, they will not send a letter regarding claims paid for foster children.
When you receive a letter from the Claims Analysis Unit notifying you that a Medicaid claim indicates that a beneficiary has an address in another state, do the following:
1. Review the case according to policy in this section to determine if the beneficiary is a resident of NC.
a. If he is a resident of NC, continue the case.
b. If he is not a resident of NC, propose termination with a timely notice.
2. No response to DMA is necessary.