Friday, July 8, 2016

Appeal letter to process the out of network claim when treated on emergency

Practice address
Po box 1234
Kenneth City FL-123456

Georgia Medicaid
Attn: Claims Department
PO Box: 7000
McRae, GA- 31055

Re: Out of state Medical Claim
Patient Name:
Insured’s Identification Number: 11107639099123
Service Date: 06/26/2010 to 07/02/2010
Call Reference#: 972217511

Dear Sir/Madam,

This is to report a claim for a service rendered in out of network state Florida. Patient was admitted in  Hospital on 06/25/2010 with acute respiratory failure which required urgent care and was referred to Dr  for an intensive consultation on 06/26/2010 and for further review till 07/02/2010. Hence we would like to request you to take the above situation into consideration and have the claims reimbursed at the earliest possible.

Herewith all supporting Medical documents are attached.

Incase of any queries or clarifications please call (407)123-4569 between 8.00 AM and 5.00 PM Monday through Friday Eastern Time.


(Account Receivable- Reimbursement Specialist)


Reimbursement for services rendered to beneficiaries is normally limited to Medicaid-enrolled providers. MDHHS reimburses out of state providers who are beyond the borderland area (defined below) if the service meets one of the following criteria:

** Emergency services as defined by the federal Emergency Medical Treatment an  Active Labor Act (EMTALA) and the Balanced Budget Act of 1997 and its regulations; or

** Medicare and/or private insurance has paid a portion of the service and the provider is billing MDHHS for the coinsurance and/or deductible amounts; or

** The service is prior authorized by MDHHS. MDHHS will only prior authorize non-emergency services to out of state/beyond borderland providers if the service is not available within the state of Michigan and borderland areas.

Note for Hospice Providers: An out-of-state/borderland hospice provider cannot cross over the border into Michigan to provide services to a Medicaid beneficiary unless:

** The agency is licensed and Medicare-certified as a hospice in Michigan; or

** The state in which the provider is licensed and certified has a reciprocal licensing agreement with the State of Michigan.

If one of these conditions is met and the hospice provides services across state lines, its personnel must be qualified (e.g., licensed) to practice in Michigan.

Medicaid will not cover services for a beneficiary who enters a hospice-owned residence outside of Michigan. The Community Health Automated Medicaid Processing System (CHAMPS) will not recognize the core-based statistical area (CBSA) code of another state. Additionally, when a Michigan Medicaid beneficiary voluntarily enters a hospice-owned residence in another state to receive routine hospice care, they are no longer considered a Michigan resident and, therefore, are not eligible for hospice benefits under Michigan Medicaid.

Note for Home Health Providers: An out-of-state/borderland home health provider cannot cross over the border into Michigan to provide services to a Medicaid beneficiary unless they are Medicare certified as a home health agency in Michigan. If this condition is met, and the home health agency provides services across state lines, its personnel must be qualified (e.g., licensed) to practice in Michigan.

Note for Nursing Facilities: The only borderland nursing facilities that are allowed to enroll with Michigan Medicaid are those facilities where Michigan beneficiaries were admitted to the facilities prior to October 1, 2007 or were admitted where placement was approved by Medicaid due to closure of a Michigan facility. To ensure that these borderland nursing facilities serving Michigan Medicaid beneficiaries have a current standard Health Survey, a Life Safety Code Survey, and a current facility license, MDHHS requires this information be sent to MDHHS each year. The review of survey and license information by MDHHS will occur prior to December 31 of each year. This information must be received by the Medicaid Provider Enrollment Unit by November 1 of each year so the borderland nursing facility Medicaid enrollment continues. (Refer to the Directory Appendix for contact information.)

Managed Care Plans follow their own Prior Authorization criteria for out of network/out of state services. Providers must be licensed and/or certified by the appropriate standard-setting authority. All providers rendering services to Michigan Medicaid beneficiaries must complete the on-line application process described in the Provider Enrollment Section of this Chapter in order to receive reimbursement.

Exceptions to this requirement may be made in special circumstances. These circumstances will be addressed through the Prior Authorization process.

Out of state/beyond borderland providers enrolled with the Michigan Medicaid program may submit their claims directly to CHAMPS. Providers should refer to the appropriate Billing and Reimbursement chapter of this manual for billing instructions.

MDHHS is prohibited by federal law from issuing Medicaid payment to any financial institution or entity whose address is outside of the United States.

Out of state/beyond borderland providers have a responsibility to follow Michigan Medicaid policies, including obtaining PA for those services that require PA.

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