Accessing Out of State Medical Coverage

Out-of-State Areas Designated as “In-State”

The IHCP designates certain border counties in surrounding states as “in-state” for prior authorization (PA) purposes. This applies to counties located within the metropolitan statistical areas (MSAs) of major cities along Indiana’s borders.

Table 1 – Out-of-State Counties Considered In-State for IHCP PA

• • Chicago-Naperville-Elgin Area: Cook, DeKalb, DuPage, Grundy, Kane, Kendall, Lake, McHenry, Will (Illinois)

  • Cincinnati Area: Boone, Bracken, Campbell, Gallatin, Grant, Kenton, Pendleton (Kentucky); Brown, Butler, Clermont, Hamilton, Warren (Ohio)

  • Louisville/Jefferson County Area: Bullitt, Henry, Jefferson, Oldham, Shelby, Spencer, Trimble (Kentucky)

  • Evansville Area: Henderson (Kentucky)

  • South Bend-Mishawaka Area: Cass (Michigan)

For a complete list of applicable ZIP codes, see the Out-of-State Areas Designated as In-State for IHCP Providers spreadsheet.

Special Circumstances for In-State Status

Providers located outside Indiana and not in the designated border counties above may still request “in-state” status during enrollment, revalidation, or an enrollment update if certain conditions apply. Eligible provider specialties may qualify if:

• Enrollment improves access to medically necessary services where travel to an in-state provider would create a financial hardship or significant burden.

• Enrollment allows members to retain a primary medical provider or access specialty services (such as centers of excellence) not otherwise available in-state.

• Transportation to an Indiana provider would cause significant undue expense or hardship.

• Enrollment is needed to address an emergency health crisis.

Step-by-Step Guide: Prior Authorization for Out-of-State, Non-Enrolled Hospitals

1. Identify the Need & Confirm Provider Status

• Confirm your child needs a treatment that can't be provided in Indiana.

• Verify the out-of-state hospital (like Cleveland Clinic) is not enrolled with Indiana Medicaid.
  
  

2. Who Submits the PA Request?

• • A Medicaid-enrolled Indiana provider must submit the request.

  • If the requesting provider is not enrolled, the PA won’t be processed and you’ll be notified.
    
    

3. Gather the Required Form & Documentation

• • Use the IHCP Prior Authorization Request Form

  • Complete these sections thoroughly:

    1. Requesting Provider Info: NPI/Provider ID, taxonomy, TIN, address, etc.

    2. Rendering Provider Info (if known): Include NPI, address, contact details.

    3. Ordering/Referring Provider (OPR): NPI of the provider who made the referral. 

    4. Patient Details: Member ID, DOB, diagnosis codes (ICD‑10).

    5. Service Details: Dates, CPT/HCPCS codes, place of service, units, estimated cost. 

    6. Clinical Notes: Explain why Indiana providers can't perform the service; attach records and a plan of care. 

    7. Signature: Must be signed by a qualified practitioner.
       
       

4. Submission Methods & Contact Details

• • For Fee-for-Service (FFS) Medicaid (i.e., no managed care involved): Submit via Acentra Health:

    • Fax: 800‑261‑2774

    • Phone: 866‑725‑9991 (inquiries) 

  • For Managed Care Plans (Healthy Indiana Plan, Hoosier Healthwise, etc.): Use the PA method or contact listed in the member’s plan reference guide.

  • IHCP Quick Reference Guide provides full contact details for submission methods.
    
    

5. Timeline & Emergency Protocols

• • Non-emergency PA: Must be submitted before services are rendered.

  • Emergency admissions: PA must be submitted within 48 hours of admission.

  • Expect a decision typically within several business days (check FFS vs. MCE-specific guidelines).
    
    

6. Decision & Appeals

• • You'll receive a PA Notification Letter with approval or denial.

  • If denied:

    1. Request administrative review.

    2. Submit additional documentation.

    3. File an appeal according to instructions in the letter and IHCP appeal protocols.
       
       

7. After PA Approval

• Provide the PA approval number to the out-of-state hospital.

• The hospital may need to complete temporary enrollment or direct billing setup to submit claims.

• Ensure the hospital includes the PA number on their submitted Medicaid claim.

IHCP Provider Enrollment – Out-of-State Providers

The IHCP Provider Enrollment Type and Specialty Matrix outlines enrollment requirements for all provider types, including out-of-state providers. This matrix specifies:

• • Required documentation for out-of-state applicants

  • Which provider types and specialties are ineligible for out-of-state enrollment

Out-of-state providers must meet the following conditions:

• • Be certified, licensed, registered, or otherwise authorized as required by the state in which they are located.

  • Fulfill the same conditions of participation as in-state providers.

  • Complete enrollment in the Indiana Health Coverage Programs (IHCP) to receive reimbursement for services provided to IHCP members.

Out-of-state providers may also enroll under the Ordering, Prescribing, or Referring (OPR) provider type if they only order, prescribe, or refer services for IHCP members.

For additional guidance:

• • See the Provider Enrollment Module for general IHCP enrollment instructions.

  • Review the Out-of-State Providers Module for rules and documentation requirements specific to providers outside Indiana.