2023 New Mexico Statutes › Chapter 27 - Public Assistance › Article 11 - Medicaid Providers › Section 27-11-2 - Definitions.

As used in the Medicaid Provider and Managed Care Act:
A. "claim" means a request for payment for services;
B. "clean claim" means a claim for reimbursement that:
(1) contains substantially all the required data elements necessary for accurate adjudication of the claim without the need for additional information from the medicaid provider or subcontractor;
(2) is not materially deficient or improper, including lacking substantiating documentation required by medicaid; and
(3) has no particular or unusual circumstances that require special treatment or that prevent payment from being made in due course on behalf of medicaid;
C. "credible" means having indicia of reliability after the state has reviewed all allegations, facts and evidence carefully and acted judiciously on a case-by-case basis;
D. "credible allegation of fraud" means an allegation that has been verified by the state from any source, including fraud hotline complaints, claims data mining and provider audits;
E. "department" means the human services department [health care authority department];
F. "fraud" means any act that constitutes fraud under state or federal law;
G. "managed care organization" means a person eligible to enter into risk-based prepaid capitation agreements with the department to provide health care and related services;
H. "medicaid" means the medical assistance program established pursuant to Title 19 of the federal Social Security Act and regulations issued pursuant to that act;
I. "medicaid provider" means a person that provides medicaid-related services to recipients;
J. "overpayment" means an amount paid to a medicaid provider or subcontractor in excess of the medicaid allowable amount, including payment for any claim to which a medicaid provider or subcontractor is not entitled;
K. "person" means an individual or other legal entity;
L. "recipient" means a person whom the department has determined to be eligible to receive medicaid-related services;
M. "secretary" means the secretary of human services; and
N. subcontractor" means a person that contracts with a medicaid provider or a managed care organization to provide medicaid-related services to recipients.
History:
Laws 1998, ch. 30, § 2; 2019, ch. 215, § 2.
ANNOTATIONS
Bracketed material.
— The bracketed material was inserted by the compiler and is not part of the law. Laws 2023, ch. 205, § 16 provided that references to the human services department shall be deemed to be references to the health care authority department.
Cross references.
— For provisions of the federal Social Security Act,
see
42 U.S.C.S. § 301 et seq.
The 2019 amendment,
effective January 1, 2020, defined "claim", "clean claim", "credible", "credible allegation of fraud", "fraud", and "overpayment", and revised the definitions of "medicaid provider" and "subcontractor", as used in the Medicaid Provider and Managed Care Act; after "Medicaid Provider", added "and Managed Care"; added new Subsections A through D and redesignated former Subsection A as Subsection E; added new Subsection F and redesignated former Subsections B through D as Subsections G through I, respectively; in Subsection I, after "person", deleted "including a managed care organization, operating under contract with the department to provide" and added "that provides"; added new Subsection J and redesignated former Subsections E through H as Subsections K through N, respectively; and in Subsection N, after "medicaid provider", added "or a managed care organization".
Severability.
— Laws 2019, ch. 215, § 19, provided that if any part or application of this act is held invalid, the remainder or its application to other situations or persons shall not be affected.