5-018.07B2 Private Health Insurance (Primary) and Medicaid (Secondary)

If the client is using private insurance as his/her primary insurance and Medicaid is secondary, Medicaid prior authorization of the out-of-state medical treatment is required.

If out-of-state treatment is approved by Medicaid, Department staff may authorize transportation. The client is not eligible for assistance if the client is driving him/herself.

If Medicaid denies prior authorization of payment for out-of-state treatment because of a non-medical reason such as the out-of-state provider refusing to participate in Medicaid, Department staff must request prior authorization from the Department Central Office Coordinator. If the Coordinator denies out-of-state transportation, Department staff must deny the transportation service. If the Coordinator approves the out-of-state transportation, Department staff must approve the transportation service.

If Medicaid denies prior authorization for out-of-state treatment due to lack of medical necessity, transportation for out-of-state treatment must also be denied.

{8/20/07}

Department staff must use the following procedure for authorizing out-of-state travel:

1. Department staff must determine if the client has received Medicaid approval for out-of-state medical treatment. If Department staff have not received the approval from Medicaid, Department staff must contact the client to have his/her doctor send medical information to the Medicaid Division for approval. (See 471 NAC 1-002.02G2 Prior Authorization Procedures for Out-of-state Services.)

2. If out-of-state treatment is approved by Medicaid, Department staff may authorize transportation. Department staff must determine if the client will travel by air or if a provider will drive the client. The client is not eligible for assistance if the client if driving him/herself.

3. If Medicaid denies prior authorization of payment for the out-of-state treatment, Department staff must obtain must obtain prior authorization as follows:

a. Department staff must submit a “Social Service Exception” (Form HHS-2A) to the Central Office Transportation Coordinator (Sue Fiero). The Social Service Exception must include the following information:

(1) Reason for the out-of-state treatment and reason for denial of out-of-state treatment;

(2) Frequency of the trips;

(3) Time period for the trips;

(4) Type of travel needed (for example, bus or air fare); and

(5) Private health insurance (if any) information regarding out-of- state treatment coverage;

b. The Central Office Transportation Coordinator will make a determination if out-of-state transportation assistance is approved and return the Social Service Exception Form HHS-2A. If approved, Department staff must use the procedure outlined in 471 NAC 27-004.05.

c. If out-of-state transportation assistance is disapproved, HHSS staff must deny the transportation service, using 471 NAC 1-002.02G as the manual reference for denial.

Air Travel: If the client is traveling by air, the Department staff must use the following procedure:

1. Department staff must contact the Service Area Designee to arrange for air travel and provide the designee with the following information:

a. Name of client and an escort (if required)

b Dates of appointment;

c. Departure date and time; and

d. Destination and return date.

2. Department staff must authorize the tickets on N-FOCUS once the electronic ticket is received for the client and escort if appropriate. The worker must forward the ticket information to the client.