One of the most common insurance barriers is getting out-of-state healthcare visits covered. Because of the challenges associated with out-of-state healthcare, it is important to have a local team (pediatrician or internist and, if needed, a neurologist) who can help provide stability in your care. Here are some helpful tips on this process:

  • The individual being seen MUST have an established primary care provider (who is licensed in the state the individual lives in) who sees them routinely. This primary care provider needs to have seen the individual at least once within the current calendar year, BEFORE an out-of-state referral is made. Medicaid coverage for out-of-state referrals is often delayed because:
    • Your primary care office staff typically need 30 days to request records and be able to review
    • Your primary care office staff must justify to your home state’s Medicaid why services need to be rendered OUTSIDE of the state, and they cannot do so without making a complete evaluation of the patient’s records.
  • Ensure insurance information is up to date. This needs to be confirmed YEARLY in January by you or the primary caregiver/parent. Especially if there are multiple insurances. Most require annual submission of forms so insurance does not lapse. Not knowing and having them “termed” or “inactive” will always result in a DELAYED care.
  • When referred to out of state care with Medicaid, ensure ACCURATE information is provided and the out-of-state provider is enrolled with that state’s Medicaid program.
    • Contact the out-of-state clinic prior to the referral being placed to see the provider(s) are enrolled.
    • IF NOT, the out-of-state team will need to complete enrollment BEFORE appointments or tests, such as imaging, can be scheduled at an out-of-state location.
    • This goes for every individual specialist that will be seeing you or your child.
    • Why does this matter? If these individuals are not properly enrolled, claims will be denied and the institution will not get paid for services rendered.
    • For those with commercial insurance, this may also be an issue; if this is not properly done on the front-end, insurance can deny service all together and leave you with the entire bill to be paid as “out of network.”
  • Understand what your local healthcare team can provide versus what you can complete at the out-of-state clinic. All services to be completed out of state need to be documented on the referral form to obtain insurance approval on the front end.
    • EVERYTHING must be approved by the state of residency’s insurance before out-of-state care can be given. Most of this is done behind the scenes and families are usually unaware of this process, but it is a common reason why things get denied “last minute.” Per Medicaid guidelines, many procedures and tests cannot even receive prior authorization too far in advance before a test. Thus, you cannot have something pre-authorized in April for an encounter in November. Most institutions have a policy on this; typically, they begin the submission of pre-approval paperwork 7-14 days before an appointment. This is why it’s very important to ensure perfect accuracy in the information you provide (local provider name, insurance information, etc.).