New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 314 - LONG TERM CARE SERVICES - WAIVERS › Part 7 - SUPPORTS WAIVER › Section 8.314.7.19 - REIMBURSEMENT

Current through Register Vol. 35, No. 13, July 16, 2024
Health care to MAP eligible recipients is furnished by a
				  variety of providers and provider groups. The reimbursement and billing for
				  these services is administered by MAD.
A.
Agency-based service delivery model
				provider reimbursement:
Upon approval of a New Mexico MAD provider
				participation agreement (PPA) by MAD or its designee, licensed practitioners,
				facilities, and other providers of services that meet applicable requirements
				are eligible to be reimbursed for furnishing covered services to MAP eligible
				recipients. A provider must be enrolled before submitting a claim for payment
				to the MAD claims processing contractors. MAD makes available on the human
				service department/medical assistance division (HSD/MAD) website, on other
				program-specific websites, or in hard copy format, information necessary to
				participate in health care programs administered by HSD or its authorized
				agents, including New Mexico administrative code (NMAC) rules, billing
				instructions, utilization review instructions, service definitions and service
				standards and other pertinent materials. When enrolled, a provider receives
				instruction on how to access these documents. It is the provider's
				responsibility to access these instructions, to understand the information
				provided and to comply with the requirements. The provider must contact HSD or
				its authorized agents to obtain answers to questions related to the material or
				not covered by the material. To be eligible for reimbursement, a provider must
				adhere to the provisions of the MAD PPA and all applicable statutes,
				regulations, and executive orders. MAD or its selected claims processing
				contractor issues payments to a provider using electronic funds transfer (EFT)
				only.
B.
Participant directed
				service delivery model provider and vendor reimbursement:
Supports
				waiver eligible recipients must follow all billing instructions provided by the
				FMA to ensure payment of service providers, employees, and vendors. Claims must
				be billed to the FMA per the billing instructions. Reimbursement to a service
				provider and a vendor in the supports waiver program is made, as follows:
(1) supports waiver service provider and
				vendor must enroll with the FMA;
(2) the eligible recipient receives
				instructions and documentation forms necessary for a service provider's and a
				vendor's claims processing;
(3) an
				eligible recipient must submit claims for payment of their supports waiver
				service provider and vendor to the FMA for processing; claims must be filed per
				the billing instructions provided by the FMA;
(4) the eligible recipient and their supports
				waiver service provider and vendor must follow all FMA billing instructions;
				and
(5) reimbursement of a supports
				waiver service provider and vendor is made at a predetermined reimbursement
				rate by the eligible recipient with the supports waiver service provider or
				vendor, approved by the TPA contractor, and documented in the ISP and in the
				supports waiver provider or vendor agreement; at no time can the total
				expenditure for services exceed the eligible recipient's AAB;
(6) the FMA must submit claims that have been
				paid by the FMA on behalf of the eligible recipient to the MAD fiscal
				contractor for processing; and
(7)
				reimbursement may not be made directly to the eligible recipient, either to
				reimburse them for expenses incurred or to enable the eligible recipient to pay
				a service provider directly.