Administrative Code

Creating a Report: Check the sections you'd like to appear in the report, then use the "Create Report" button at the bottom of the page to generate your report. Once the report is generated you'll then have the option to download it as a pdf, print or email the report.

Virginia Administrative Code
Title 12. Health
Agency 30. Department of Medical Assistance Services
Chapter 60. Standards Established and Methods Used to Assure High Quality Care
7/13/2020

12VAC30-60-21. Utilization Control of Nonparticipating Out-of-State Inpatient Hospitals.

Inpatient hospital services provided out of state to a Medicaid recipient who is a resident of the Commonwealth of Virginia shall only be reimbursed under any one of the following conditions. It shall be the responsibility of the hospital, when requesting prior authorization for the admission, to demonstrate that one of the following conditions exists in order to obtain authorization. It shall be the responsibility of the admitting physician to adhere to these restrictions. Services provided out of state for circumstances other than these specified exceptions shall not be covered. When, during post payment utilization review, inappropriate or inaccurate payments are determined to have been made for reasons other than those specified herein, DMAS shall recover the inappropriately expended funds.

1. The medical services must be needed because of a medical emergency;

2. Medical services must be needed and the recipient's health would be endangered if he were required to travel to his state of residence;

3. The state determines, on the basis of medical advice, that the needed medical services, or necessary supplementary resources, are more readily available in the other state;

4. It is general practice for recipients in a particular locality to use medical resources in another state.

Statutory Authority

§ 32.1-325 of the Code of Virginia.

Historical Notes

Derived from Volume 18, Issue 06, eff. January 2, 2002.

Website addresses provided in the Virginia Administrative Code to documents incorporated by reference are for the reader's convenience only, may not necessarily be active or current, and should not be relied upon. To ensure the information incorporated by reference is accurate, the reader is encouraged to use the source document described in the regulation.

As a service to the public, the Virginia Administrative Code is provided online by the Virginia General Assembly. We are unable to answer legal questions or respond to requests for legal advice, including application of law to specific fact. To understand and protect your legal rights, you should consult an attorney.