Out-of-State Services

Under 42 CFR 431.52, out-of-state coverage is required under a variety of circumstances. This citation says states must pay for services furnished in another state to the same extent it would pay for services furnished within its boundaries as long as the service is provided to an Alabama Medicaid recipient and any of the four following conditions is met:

• Medical services are needed due to a medical emergency.
• Medical services are needed, and the recipient’s health would be endangered if they were required to travel to their state of residence.
• The state determines, on the basis of medical advice, that the needed medical services, or necessary supplementary services, are more readily available in the other state.
• It is general practice for recipients in a particular locality to use medical resources in another state.
  

An out-of-state medical provider must agree to enroll as a provider with the Alabama Medicaid Agency. Some services must be approved before the service can be given by an out-of-state provider. Different provider types have specific criteria for out-of-state enrollment. Please see below for more information.

Medical and Hospital Providers

For Medical and Hospital providers seeking medical services out-of-state:

• The referring provider must review, complete, and submit the out-of-State Request Form: https://medicaid.alabama.gov/content/9.0_Resources/9.4_Forms_Library/9.4.20_Out_of_State_Service.aspx

  *NOTE: Please review the Instructions prior to completing the form.

• Provider Enrollment: https://medicaid.alabama.gov/content/10.0_Contact/10.3_Provider_Contacts/10.3.4_Provider_Enrollment.aspx
• Providers Home: https://medicaid.alabama.gov/content/7.0_Providers/
  • Provider Manuals
  • Fee Schedules
  • Prior Authorization

Pharmacy and DME Providers

For Pharmacy and DME providers, please refer to the Provider Enrollment & Forms page at https://medicaid.alabama.gov/content/10.0_Contact/10.3_Provider_Contacts/10.3.4_Provider_Enrollment.aspx to contact the Gainwell Provider Enrollment Unit for program-specific out-of-state enrollment.