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Medicaid Out-of-state Member Claims and Provider Enrollment Requirements

Posted May 16, 2016

Blue Cross and Blue Shield Plans currently administer Medicaid programs in California, Delaware, Hawaii, Illinois, Indiana, Kentucky, Michigan, Minnesota, New Jersey, New Mexico, New York, Pennsylvania, Puerto Rico, South Carolina, Tennessee, Texas, Virginia and Wisconsin as a Managed Care Organization (MCO), providing comprehensive Medicaid benefits to the eligible population. 

Because Medicaid is a state-run program, requirements vary for each state, and thus each Blue Cross and Blue Shield Plan. Medicaid members have limited out-of-state benefits, generally covering only emergency situations. In some cases, such as children attending college out-of-state, or a lack of specialists in the member’s home state, a Medicaid member may receive care in another state; however, benefit prior authorization is generally required. 

As a reminder, claims for out-of-state Blue Cross and Blue Shield Medicaid members should be submitted to Blue Cross and Blue Shield of Illinois (BCBSIL). If you are contracted with BCBSIL for Medicaid, your local Medicaid rates will only apply for BCBSIL members; they do not apply to out-of-state Medicaid members. When you see a Medicaid member from another state and submit a claim, you must accept the Medicaid fee schedule that applies in the member’s home state. 

ALERT! OUT-OF-STATE PROVIDER ENROLLMENT MAY BE REQUIRED

Some states require that out-of-state providers enroll in their state’s Medicaid program in order to be reimbursed. Some states may accept a provider’s Medicaid enrollment in the state where they practice to fulfill this requirement. Refer to the Medicaid Enrollment Requirements by State  for details. 

If you are required to enroll in another state’s Medicaid program, you should receive notification upon submitting an eligibility or benefit inquiry. If you submit a claim to BCBSIL without enrolling when enrollment is required for an out-of-state Medicaid member, you will be required to enroll before the Medicaid claim can be processed and before you receive reimbursement. 

For additional information, such as Identifying Medicaid Members to Determine Eligibility and Benefits, Medicaid Billing Data Requirements, Commonly Asked Questions and more, refer to the Claims Handling for Medicaid Members.  

Checking eligibility and/or benefit information is not a guarantee of payment. Please note that the fact that a guideline is available for any given treatment, or that a service has been preauthorized, is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility and the terms of the member’s certificate of coverage applicable on the date services were rendered. If you have any questions, please call the number on the member’s ID card.