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BAM 402 13 of 20 MA BENEFITS BPB 2021-026 10-1-2021

BRIDGES ADMINISTRATIVE MANUAL STATE OF MICHIGAN DEPARTMENT OF HEALTH & HUMAN SERVICES

• The beneficiary is temporarily out-of-state and the services are necessary because of a medical/dental emergency (as defined by the program). • The service is prior authorized by MDHHS as more readily available in another state. Prior Authorization Certain services provided by borderland providers require prior authorization the same as services requiring prior authorization by Michigan providers. Except in emergencies, the services of a beyond borderland pro- vider must be prior authorized. The beneficiary's local physician should submit the following to MDHHS: • Documentation of the need for beyond borderland services. • Beneficiary identification. • Eligibility data. The address to submit the above information is: Michigan Department of Health and Human Services Review and Evaluation Division 400 S. Pine Street PO Box 30170 Lansing, MI 48909-7979 The beneficiary's physician and the local office may also make tele- phone inquiries regarding beyond borderland services when it appears that time is of the essence. Phone: 1-800-622-0276 The Prior Authorization and Review Section may request informa- tion from local offices when evaluating the need for beyond border- land services. Prompt assistance from the local offices is appreciated. A copy of the prior authorization decision will be sent to the appropriate local office. Inquiries Refer non-enrolled provider questions about borderland or beyond borderland coverage and billings to: Michigan Department of Health and Human Services