reglab/statecodes huggingface dataset:
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 315 - OTHER LONG TERM CARE SERVICES › Part 2 - PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) › Section 8.315.2.23 - QUALITY ASSURANCE SYSTEM

Current through Register Vol. 35, No. 13, July 16, 2024
A. The
				provider will have a written plan of quality assurance and improvement which
				provides for a system of ongoing assessment, implementation, evaluation, and
				revision of activities related to overall program administration and services.
				The plan will:
(1) ensure that standards are
				incorporated into the provider policy and procedure manual; the provider
				standards will be based on the PACE protocol, applicable PACE standards and
				applicable licensing and certification criteria;
(2) ensure that goals and objectives provide
				a framework for quality improvement activities, evaluation and corrective
				action;
(3) ensure that quality
				indicators are objective and measurable variables related to the entire range
				of services provided by the PACE program provider; the methodology should
				assure that all demographic groups, all care settings, e.g., inpatient, the
				PACE program center and in-home, will be included in the scope of the quality
				assurance review;
(4) ensure that
				quality indicators are selected for review on the basis of high volume, high
				risk diagnosis or procedure, adverse outcomes, or some other problem-focused
				method consistent with the state of the art;
(5) ensure that the evaluation process or
				procedures review the effectiveness of the interdisciplinary team in its
				ability to assess participants care needs, identify the participant's treatment
				goals, assess effectiveness of interventions, evaluate adequacy and
				appropriateness of service utilization and reorganize treatment plan as
				necessary;
(6) establish the
				composition and responsibilities of a quality assurance committee and an ethics
				committee;
(7) ensure participant
				involvement in the quality assurance plan and evaluation of satisfaction with
				services; and
(8) designate an
				individual to coordinate and oversee implementation of quality assurance
				activities.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 315 - OTHER LONG TERM CARE SERVICES › Part 2 - PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) › Section 8.315.2.24 - DATA GATHERING/REPORTING SYSTEM

Current through Register Vol. 35, No. 13, July 16, 2024
A. Standardized data: The provider will
				ensure the quality of the data according to MAD medium and frequency of
				reporting.
B. Software: The
				provider shall make no use of computer software developed pursuant to the
				contract, except as provided in the contract or as specifically granted in
				writing by the HCA.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 315 - OTHER LONG TERM CARE SERVICES › Part 2 - PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) › Section 8.315.2.25 - FINANCIAL REPORTING

Current through Register Vol. 35, No. 13, July 16, 2024
The provider is required to submit certain financial reports
				  as follows.
A. A budgeted versus
				actual financial report for the current and year-to-date periods on a monthly
				basis 45 days after the end of each month. During the first year of operation,
				the financial report will be submitted on a monthly basis, 45 days after the
				end of each month. Thereafter, this report will be submitted on a quarterly
				basis, 45 days after the end of each quarter. The state medicaid agency
				reserves the right to extend the submission of this report on a monthly basis
				should provider performance indicate a need for more frequent
				monitoring.
B. Fiscal data based on
				cost center accounting structure provided by the state medicaid agency. At the
				twelfth month, the year-to-date summary will provide the necessary annual
				data.
C. Submit a cumulative report
				to the state medicaid agency in the form and detail described by On Lok senior
				health services/national PACE association. The interim cost report is due 45
				days after the end of each providers fiscal quarter and covers the period from
				the beginning of the fiscal year through the respective quarter.
D. Submit to the state medicaid agency a cost
				report in the form and detail prescribed by the state medicaid program no later
				than 180 days after the end of the providers fiscal year.
E. Submit to the state medicaid agency a
				quarterly balance sheet for those PACE program providers that are separate
				corporate entities.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 315 - OTHER LONG TERM CARE SERVICES › Part 2 - PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) › Section 8.315.2.26 - UTILIZATION REVIEW

Current through Register Vol. 35, No. 13, July 16, 2024
All medicaid services, including services covered under the
				  PACE program, are subject to utilization review for medical necessity and
				  program compliance. Reviews can be performed before services are furnished,
				  after services are furnished and before payment is made, or after payment is
				  made. See 8.302.5 NMAC,
Prior Authorization and Utilization
				  Review
. Once enrolled, providers receive instructions and
				  documentation forms necessary for prior authorization and claims
				  processing.
A. Prior authorization: To
				be eligible for the PACE program, a medicaid recipient must require a nursing
				facility level of care (LOC). Level of care determinations are made by MAD or
				its designee. The plan of care (POC) developed by the recipients
				interdisciplinary team must specify the type, amount and duration of service.
				Some services specified in the POC may require prior authorization from MAD or
				its designee. Services for which prior authorization was obtained remain
				subject to utilization review at any point in the payment process.
B. Eligibility determination: Prior
				authorization of service does not guarantee that individuals are eligible for
				medicaid. Providers must verify that individuals are financially and medically
				eligible for medicaid at the time services are furnished and determine if
				medicaid recipients have other health insurance.
C. Reconsideration: Providers who disagree
				with prior authorization request denials or other review decisions may request
				a re-review and a reconsideration. See MAD-953,
Reconsideration of
				Utilization Review Decisions
.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 315 - OTHER LONG TERM CARE SERVICES › Part 2 - PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) › Section 8.315.2.27 - REIMBURSEMENT

Current through Register Vol. 35, No. 13, July 16, 2024
PACE program providers must submit claims for reimbursement
				  on the UB 92 claim form or its successor.
See 8.302.2 NMAC,
Billing for Medicaid
				  Services
. Once enrolled, providers receive instructions on
				  documentation, billing and claims processing.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 320 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT) SERVICES › Part 2 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT) SERVICES › Section 8.320.2.1 - ISSUING AGENCY

Current through Register Vol. 35, No. 13, July 16, 2024
New Mexico Health Care Authority.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 320 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT) SERVICES › Part 2 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT) SERVICES › Section 8.320.2.2 - SCOPE

Current through Register Vol. 35, No. 13, July 16, 2024
The rule applies to the general public.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 320 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT) SERVICES › Part 2 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT) SERVICES › Section 8.320.2.3 - STATUTORY AUTHORITY

Current through Register Vol. 35, No. 13, July 16, 2024
The New Mexico medicaid program and other health care
				  programs are administered pursuant to regulations promulgated by the federal
				  department of health and human services under Title XIX of the Social Security
				  Act as amended or by state statute. See NMSA 1978, Section 27-1-12 et seq.
				  Section 9-8-1 et seq. NMSA 1978 establishes the health care authority (HCA) as
				  a single, unified department to administer laws and exercise functions relating
				  to health care facility licensure and health care purchasing and
				  regulation.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 320 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT) SERVICES › Part 2 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT) SERVICES › Section 8.320.2.4 - DURATION

Current through Register Vol. 35, No. 13, July 16, 2024
Permanent.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 320 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT) SERVICES › Part 2 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT) SERVICES › Section 8.320.2.5 - EFFECTIVE DATE

Current through Register Vol. 35, No. 13, July 16, 2024
January 1, 2014, unless a later date is cited at the end of a
				  section.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 320 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT) SERVICES › Part 2 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT) SERVICES › Section 8.320.2.6 - OBJECTIVE

Current through Register Vol. 35, No. 13, July 16, 2024
The objective of this rule is to provide instructions for the
				  service portion of the New Mexico medical assistance programs
				  (MAP).
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 320 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT) SERVICES › Part 2 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT) SERVICES › Section 8.320.2.7 - DEFINITIONS

Current through Register Vol. 35, No. 13, July 16, 2024
Electronic visit verification (EVV):A telephone and
				  computer-based system that electronically verifies the occurrence of HSD
				  selected services visits and documents the precise time the service begins and
				  ends.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 320 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT) SERVICES › Part 2 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT) SERVICES › Section 8.320.2.8 - MISSION STATEMENT

Current through Register Vol. 35, No. 13, July 16, 2024
To transform lives. Working with our partners, we design and
				  deliver innovative, high quality health and human services that improve the
				  security and promote independence for New Mexicans in their
				  communities.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 320 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT) SERVICES › Part 2 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT) SERVICES › Section 8.320.2.9 - EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
The medical assistance division (MAD) pays for medically
				  necessary health services including preventive, treatment and ameliorative
				  services for a medical assistance program (MAP) eligible recipient under 21
				  years of age through the early and periodic screening, diagnostic and treatment
				  (ESPDT) services program. See
				  42 CFR 441.50
				  Subpart B.
A. EPSDT description:
(1) early: assessing health care early in
				life so that potential disease and disabilities can be prevented or detected in
				their preliminary stages, when they are most effectively treated;
(2) periodic: assessing a child's health at
				regular recommended intervals in the child's life to assure continued healthy
				development;
(3) screening: the use
				of tests and procedures to determine if children being examined have conditions
				warranting closer medical or dental attention;
(4) diagnostic: the determination of the
				nature or cause of conditions identified by the screening; and
(5) treatment: the provision of services
				needed to control, correct or lessen health problems.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 320 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT) SERVICES › Part 2 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT) SERVICES › Section 8.320.2.10 - GENERAL EPSDT SCREENINGS AND REFERRALS

Current through Register Vol. 35, No. 13, July 16, 2024
EPSDT includes a screening component called the "tot to teen
				  healthcheck". EPSDT also includes diagnostic, treatment, and other necessary
				  health care measures needed to correct or ameliorate physical and behavioral
				  health disorders or conditions discovered during the tot to teen healthcheck or
				  through other diagnostic evaluations or assessments.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 320 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT) SERVICES › Part 2 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT) SERVICES › Section 8.320.2.11 - INFORMATION GIVEN TO MAP ELIGIBLE RECIPIENTS

Current through Register Vol. 35, No. 13, July 16, 2024
A. A MAP eligible recipient under 21 years of
				age, or his or her family, is provided with the following information:
(1) benefits of preventive health
				care;
(2) services available under
				EPSDT and where and how to access those services;
(3) services provided under EPSDT are
				furnished at no cost to a MAP eligible recipient;
(4) transportation and scheduling assistance
				is available upon request; and
(5)
				the right to request a HSD administrative hearing.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 320 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT) SERVICES › Part 2 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT) SERVICES › Section 8.320.2.12 - EPSDT ELIGIBLE PROVIDERS

Current through Register Vol. 35, No. 13, July 16, 2024
Upon MAD's approval of a PPA, a licensed practitioner, agency
				  or facility that meets applicable requirements is eligible to be reimbursed for
				  furnishing covered services to a MAP eligible recipient. A provider must be
				  enrolled before submitting a claim for payment to the appropriate MAD claims
				  processing contractor. MAD makes available on the HSD/MAD websites, on other
				  program-specific or in hard copy format, information necessary to participate
				  in health care programs administered by HSD or its authorized agents, including
				  MAD New Mexico administrative code (NMAC) rules, billing instructions,
				  utilization review (UR) instructions and other pertinent materials. Once
				  enrolled, a provider receives instructions on how to access these documents.
				  MAD makes available on the 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 program rules,
				  billing instructions, UR instructions, and other pertinent material. To be
				  eligible for reimbursement, a provider is bound by the provisions of the MAD
				  PPA.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 320 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT) SERVICES › Part 2 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT) SERVICES › Section 8.320.2.13 - PROVIDER RESPONSIBILITIES AND REQUIREMENTS

Current through Register Vol. 35, No. 13, July 16, 2024
A. A provider who furnishes services to a MAP
				eligible recipient must comply with all federal, state, local laws, rules,
				regulations, executive orders and the provisions of the provider participation
				agreement (PPA). A provider must adhere to MAD program rules as specified in
				NMAC rules and program policies that include but are not limited to
				supplements, billing instructions, and UR directions, as updated. The provider
				is responsible for following coding manual guidelines and centers for medicare
				and medicaid services (CMS) correct coding initiatives, including not
				improperly unbundling or upcoding services.
B. A provider must verify an individual is
				eligible for a specific MAD service and verify the recipient's enrollment
				status at time of service as well as determine if a copayment is applicable or
				if services require prior authorization. A provider must determine if a MAP
				eligible recipient has other health insurance. A provider must maintain records
				that are sufficient to fully disclose the extent and nature of the services
				provided to a MAP eligible recipient.
C. Services furnished to a MAP eligible
				recipient must be within the scope of practice defined by the provider's
				licensing board, scope of practice act, or regulatory authority.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 320 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT) SERVICES › Part 2 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT) SERVICES › Section 8.320.2.15 - TOT TO TEEN HEALTHCHECK

Current through Register Vol. 35, No. 13, July 16, 2024
MAD developed the tot to teen healthcheck, the screening
				  segment of EPSDT services. The tot to teen healthcheck includes periodic
				  screening and regularly scheduled assessments of the MAP eligible recipient's
				  general physical growth and development as well as behavioral health and social
				  emotional development.
A. Primary care
				providers (PCP), dentists, psychologists, IHS public health clinics, federally
				qualified health center (FQHC), rural health clinic (RHC), community mental
				health centers (CMHC), hospitals, school-based clinics, independent certified
				or licensed nurse practitioners and other health care providers may perform tot
				to teen healthcheck screens or partial health screenings. A provider must meet
				the participation requirements specified in applicable sections of NMAC rules.
				Tot to teen healthcheck screens must be furnished within the scope of the
				provider's practice, as defined by law.
B. Screening services are furnished to a MAP
				eligible recipient under 21 years of age. Referrals or treatment for conditions
				detected during a complete or a partial screen which require further treatment
				are then covered as part of MAD's EPSDT services. A tot to teen healthcheck can
				be performed during an office visit for an acute illness as long as the illness
				does not affect the results or the screening process.
(1) Screening schedule for medical
				components:
(a) The MAD tot to teen
				healthcheck periodicity schedule allows for a total of 25 screens. Screenings
				are encouraged at the following intervals:
(i)
				under age one: six screenings (birth, one, two, four, six and nine
				months)
(ii) ages one-two: four
				screenings (12, 15, 18 and 24 months)
(iii) ages three-five: three screenings
				(three, four and five years)
(iv)
				ages six-nine: two screenings (six and eight years)
(v) ages 10-14: four screenings (10, 12, 13
				and 14 years)
(vi) ages 15-18: four
				screenings (15, 16, 17 and 18 years)
(vii) ages 19-20: two screenings (19 and 20
				years).
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 320 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT) SERVICES › Part 2 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT) SERVICES › Section 8.320.2.16 - EPSDT SPECIAL REHABILITATION (FAMILY INFANT TODDLER EARLY INTERVENTION) SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
MAD special rehabilitation services are furnished through
				  the New Mexico early childhood education and care department (ECECD) family
				  infant toddler (FIT) program. FIT provides early intervention services for a
				  MAP eligible that has or is at risk of having a developmental delay from birth
				  to his or her third birth year. Developmental delay or at risk of is defined by
				  ECECD. A MAP eligible recipient with a developmental delay or who is at risk of
				  having a developmental delay is not considered to have a diagnosis of an
				  intellectual or developmental disability. FIT services include evaluation,
				  diagnostics and treatment necessary to correct or treat any defects or
				  conditions or to teach compensatory skills for deficits that directly result
				  from a medical or behavioral health condition. The appropriate information from
				  evaluation and diagnostics is interpreted and integrated in the individual
				  family service plan (IFSP). If the need for special rehabilitation is
				  identified outside of the tot to teen healthcheck process, the MAP eligible
				  recipient's PCP must be notified of the results and be included in the
				  treatment plan development, if the PCP so elects.
A. MAD EPSDT special rehabilitation eligible
				providers: An enrolled MAD agency certified by ECECD as a special
				rehabilitation services provider is eligible to be reimbursed for furnishing
				special rehabilitation services to a MAP eligible recipient. Individual
				providers rendering special rehabilitation services that are employed by or
				contracted by a MAD special rehabilitation provider agency must meet applicable
				ECECD standards. A provider shall:
(1) render
				special rehabilitation services under the direction of a professional acting
				within his or her scope of practice as defined by state law;
(2) render special rehabilitation services in
				the most appropriate least restrictive environment;
(3) assure that claiming for special
				rehabilitation services does not duplicate claiming for EPSDT administrative
				outreach services or services funded under the state general fund ECECD
				contract.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 320 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT) SERVICES › Part 2 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT) SERVICES › Section 8.320.2.17 - EPSDT CASE MANAGEMENT SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
MAD pays for case management services furnished to a
				  medically at risk MAP eligible recipient under 21 years of age as an EPSDT
				  service. The need for case management services must be identified in the tot to
				  teen healthcheck screen or through other diagnostic evaluations or
				  assessments.
A. EPSDT case management
				eligible providers: A qualified MAD enrolled case management agency is eligible
				to be reimbursed for furnishing services to a MAP eligible recipient. An agency
				must demonstrate direct experience in successfully serving medically at risk
				individuals under the age of 21 years and demonstrate knowledge of available
				community services and methods for gaining access to those services.
(1) The following agencies can furnish case
				management services:
(a) a governmental
				agency;
(b) a native Indian tribal
				government;
(c) the IHS;
(d) a FQHC; and
(e) a community case management
				agency.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 320 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT) SERVICES › Part 2 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT) SERVICES › Section 8.320.2.18 - EPSDT PERSONAL CARE SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
MAD pays for medically necessary personal care services
				  (PCS) furnished to a MAP eligible recipient under 21 years of age as part of
				  the EPSDT program when the services are part of his or her ISP for the
				  treatment of correction, amelioration, or prevention of deterioration of a MAD
				  identified medical or behavioral health condition, see
				  42 CFR Section
				  440.167. PCS provides a range of services to
				  a MAP eligible recipient who is unable to perform some or all activities of
				  daily living (ADLs) or instrumental activities of daily living (IADLs) because
				  of a disability or a functional limitation. A prescribed course of regular PCS
				  services and daily living assistance supports the MAP eligible recipient to
				  live in his or her home rather than an institution and allows him or her to
				  achieve the highest possible level of independence. These services include, but
				  are not limited to, activities such as bathing, dressing, grooming, eating,
				  toileting, shopping, transporting, caring for assistance animals, cognitive
				  assistance, and communicating. A MAP eligible recipient may be physically
				  capable of performing ADLs or IADLs but may have limitations in performing
				  these activities because of a cognitive impairment. PCS services may be
				  required because a cognitive impairment prevents a MAP eligible recipient from
				  knowing when or how to carry out the task. In such cases, PCS services may
				  include cuing along with supervision to ensure that the MAP eligible recipient
				  performs the task properly.
A. EPSDT
				PCS eligible providers:
(1) agencies that meet
				the following conditions are eligible to enroll as providers and be reimbursed
				for providing EPSDT PCS services:
(a) a
				licensed nursing or home health agency that is a public agency, a private
				for-profit agency, or private non-profit agency; and
(b) the PCS attendant to the MAP eligible
				recipient must be supervised by a MAD enrolled RN;
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 320 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT) SERVICES › Part 2 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT) SERVICES › Section 8.320.2.19 - EPSDT PRIVATE DUTY NURSING SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
MAD pays for private duty nursing (PDN) services as part of
				  the EPSDT program, see
				  42 CFR Section
				  441.57. Services must be accessed through the
				  tot to teen healthcheck screen. A MAP eligible recipient is under 21 years, who
				  has been referred for PDN services shift care (not intermittent care), must
				  meet the established medically fragile criteria and parameters that have been
				  approved by MAD.
A. EPSDT PDN eligible
				providers
:
A nurse working for a MAD approved PDN agency must have
				a RN or LPN on staff that meets MAD requirements. Services must be furnished
				under the direction of the MAP eligible recipient's PCP. Certification for
				participation as a medicare home health agency is not required. The following
				agencies are eligible to be reimbursed for providing EPSDT PDN services:
(1) a licensed nursing agency; or
(2) a FQHC.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 320 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT) SERVICES › Part 2 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT) SERVICES › Section 8.320.2.20 - EPSDT REHABILITATION SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
MAD pays for medically necessary services, including
				  outpatient services furnished to a MAP eligible recipient under 21 years of age
				  by or under the supervision of licensed PT; OT; and master's level SLP. A MAP
				  eligible recipient under 21 years of age who is eligible for a home and
				  community based waiver program receives medically necessary rehabilitation
				  services through the EPSDT rehabilitation services, the home and community
				  based waiver program provides rehabilitation services only for the purpose of
				  community integration.
A. EPSDT
				rehabilitation eligible providers: A PT, OT and master's level SLP is eligible
				to be reimbursed for furnishing services to a MAP eligible recipient under 21
				years of age in need of EPSDT rehabilitation services. The following providers
				are eligible to be reimbursed for furnishing outpatient rehabilitation services
				to a MAP eligible recipient:
(1) a master's
				level SLP licensed by the regulation and licensing department (RLD) board of
				speech-language pathology and audiology;
(2) a PT licensed as physical therapists by
				the RLD physical therapy board;
(3)
				an OT licensed as occupational therapists by the RLD board of examiners for
				occupational therapy;
(4) certified
				outpatient rehabilitation centers with a primary emphasis on physical therapy,
				occupational therapy or speech therapy, licensed by DOH;
(5) home health agencies licensed and
				certified by DOH; and
(6) general
				hospitals eligible to provide outpatient rehabilitation services licensed and
				certified by the DOH;
(7) a PT
				assistant licensed by the RLD physical therapy board and working under the
				supervision of a licensed PT;
(8)
				an OT assistant licensed by the RLD occupational therapy board and working
				under the supervision of a licensed OT;
(9) a SLP licensed by the RLD board of
				speech-language pathology and audiology; and
(10) SLP apprentices and clinical fellows
				licensed by the RLD board of speech-language pathology and working under the
				supervision of a licensed SLP.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 320 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT) SERVICES › Part 6 - SCHOOL-BASED SERVICES FOR MAP ELIGIBLE RECIPIENTS UNDER TWENTY-ONE YEARS OF AGE › Section 8.320.6.1 - ISSUING AGENCY

Current through Register Vol. 35, No. 13, July 16, 2024
New Mexico Health Care Authority.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 320 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT) SERVICES › Part 6 - SCHOOL-BASED SERVICES FOR MAP ELIGIBLE RECIPIENTS UNDER TWENTY-ONE YEARS OF AGE › Section 8.320.6.2 - SCOPE

Current through Register Vol. 35, No. 13, July 16, 2024
The rule applies to the general public.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 320 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT) SERVICES › Part 6 - SCHOOL-BASED SERVICES FOR MAP ELIGIBLE RECIPIENTS UNDER TWENTY-ONE YEARS OF AGE › Section 8.320.6.3 - STATUTORY AUTHORITY

Current through Register Vol. 35, No. 13, July 16, 2024
The New Mexico medicaid program and other health care
				  programs are administered pursuant to regulations promulgated by the federal
				  department of health and human services under Title XIX of the Social Security
				  Act as amended or by state statute. See Section 27-1-12 et seq NMSA 1978.
				  Section 9-8-1 et seq. NMSA 1978 establishes the health care authority (HCA) as
				  a single, unified department to administer laws and exercise functions relating
				  to health care facility licensure and health care purchasing and
				  regulation.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 320 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT) SERVICES › Part 6 - SCHOOL-BASED SERVICES FOR MAP ELIGIBLE RECIPIENTS UNDER TWENTY-ONE YEARS OF AGE › Section 8.320.6.4 - DURATION

Current through Register Vol. 35, No. 13, July 16, 2024
Permanent.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 320 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT) SERVICES › Part 6 - SCHOOL-BASED SERVICES FOR MAP ELIGIBLE RECIPIENTS UNDER TWENTY-ONE YEARS OF AGE › Section 8.320.6.5 - EFFECTIVE DATE

Current through Register Vol. 35, No. 13, July 16, 2024
July 1, 2015, unless a later date is cited at the end of a
				  section.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 320 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT) SERVICES › Part 6 - SCHOOL-BASED SERVICES FOR MAP ELIGIBLE RECIPIENTS UNDER TWENTY-ONE YEARS OF AGE › Section 8.320.6.6 - OBJECTIVE

Current through Register Vol. 35, No. 13, July 16, 2024
The objective of these rules is to provide instruction for
				  the service portion of the New Mexico medical assistance division's (MAD)
				  medical assistance programs (MAP).
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 320 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT) SERVICES › Part 6 - SCHOOL-BASED SERVICES FOR MAP ELIGIBLE RECIPIENTS UNDER TWENTY-ONE YEARS OF AGE › Section 8.320.6.7 - DEFINITIONS (Reserved)

Current through Register Vol. 35, No. 13, July 16, 2024
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 320 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT) SERVICES › Part 6 - SCHOOL-BASED SERVICES FOR MAP ELIGIBLE RECIPIENTS UNDER TWENTY-ONE YEARS OF AGE › Section 8.320.6.8 - MISSION STATEMENT

Current through Register Vol. 35, No. 13, July 16, 2024
To transform lives. Working with our partners, we design and
				  deliver innovative, high quality health and human services that improve the
				  security and promote independence for New Mexicans in their
				  communities.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 320 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT) SERVICES › Part 6 - SCHOOL-BASED SERVICES FOR MAP ELIGIBLE RECIPIENTS UNDER TWENTY-ONE YEARS OF AGE › Section 8.320.6.9 - SCHOOL-BASED SERVICES FOR RECIPIENTS UNDER TWENTY-ONE YEARS OF AGE

Current through Register Vol. 35, No. 13, July 16, 2024
MAD pays for medically necessary services for a MAP eligible
				  recipient under twenty-one years of age when the services are part of the MAP
				  eligible recipient's (eligible recipient's) individualized education program
				  (IEP) or an individualized family service plan (IFSP), a section 504
				  accommodation plan pursuant to 34 CFR 104 Subpart D (504 plan), an individual
				  health care plan (IHCP), or are otherwise medically necessary as appropriate
				  for each covered service for treatment (correction, amelioration, or prevention
				  of deterioration) of an identified medical condition.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 320 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT) SERVICES › Part 6 - SCHOOL-BASED SERVICES FOR MAP ELIGIBLE RECIPIENTS UNDER TWENTY-ONE YEARS OF AGE › Section 8.320.6.10 - GENERAL PROVIDER INSTRUCTIONS

Current through Register Vol. 35, No. 13, July 16, 2024
Health care to New Mexico MAP eligible recipients is
				  furnished by a variety of providers and provider groups. The reimbursement for
				  these services is administered by MAD. Upon approval of a 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 MAD covered services to MAP
				  eligible recipients. A provider must be approved before submitting a claim for
				  payment to the MAD claims processing contractors. MAD makes available on the
				  HSD website, on other program-specific websites, or in hard copy format,
				  information necessary to participate in health care programs administered by
				  HSD/MAD or its authorized agents, including program rules, billing
				  instructions, utilization review (UR) instructions, and other pertinent
				  materials. When approved, 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, rules, and executive orders.
				  MAD or its selected claims processing contractor issues payment to a provider
				  using the electronic funds transfer (EFT) only. Providers must supply necessary
				  information in order for payment to be made. Services must be provided within
				  the scope of the practice and licensure for each agency, each rendering
				  provider within that agency and each individual provider. Services must be in
				  compliance with the statutes, rules and regulations of his or her
				  practitioner's applicable practice board and act. Providers must be eligible
				  for reimbursement as described in 8.310.3 NMAC.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 320 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT) SERVICES › Part 6 - SCHOOL-BASED SERVICES FOR MAP ELIGIBLE RECIPIENTS UNDER TWENTY-ONE YEARS OF AGE › Section 8.320.6.12 - PROVIDER RESPONSIBILITIES

Current through Register Vol. 35, No. 13, July 16, 2024
A.
General responsibilities:
(1) A
				provider who furnishes services to an eligible recipient must comply with all
				terms and conditions of his or her MAD PPA and the MAD New Mexico
				administrative code (NMAC) rules.
(2) A provider must verify that an individual
				is an eligible recipient at the time services are billed.
(3) A provider must appoint a program liaison
				and backup alternate for each LEA, REC or other SFEA, who will be responsible
				for receiving and disbursing all communication, information and guidelines from
				HSD regarding the MAD school-based services program, including information on,
				but not limited to, direct services and administrative claiming.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 320 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT) SERVICES › Part 6 - SCHOOL-BASED SERVICES FOR MAP ELIGIBLE RECIPIENTS UNDER TWENTY-ONE YEARS OF AGE › Section 8.320.6.13 - COVERED SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
MAD covers the following services when medically necessary
				  and rendered as part of an eligible recipient's IEP, IFSP, 504 plan, IHCP or
				  other care plan by specified providers in school settings.
A. For services in Subsections A - E of
				8.320.6.13 NMAC, a provider must first develop and then update the eligible
				recipient's present level of performance for each of his or her IEP or IFSP
				cycles. 504 plans, IHCPs or other care plans should be reviewed annually to
				establish ongoing medical necessity for services. MAD requires the following
				elements be included in the provider's treatment notes:
(1) the specific activity provided to the MAP
				eligible recipient for each date of service billed;
(2) a description of the level of engagement
				and the ability of the eligible recipient for each date of service billed;
				and
(3) the outcomes of session on
				the impact on the eligible recipient's exceptionality for each date of service
				billed.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 320 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT) SERVICES › Part 6 - SCHOOL-BASED SERVICES FOR MAP ELIGIBLE RECIPIENTS UNDER TWENTY-ONE YEARS OF AGE › Section 8.320.6.14 - INDIVIDUALIZED TREATMENT PLAN

Current through Register Vol. 35, No. 13, July 16, 2024
A. The
				ITP must specify:
(1) the eligible recipient's
				objectives and goals; and
(2) the
				duration, the frequency of the service for the eligible recipient.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 320 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT) SERVICES › Part 6 - SCHOOL-BASED SERVICES FOR MAP ELIGIBLE RECIPIENTS UNDER TWENTY-ONE YEARS OF AGE › Section 8.320.6.15 - NON-COVERED SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
MAD school-based services billed in school settings are
				  subject to the limitations and coverage restrictions that exist for other MAD
				  services; see 8.301.3 NMAC. MAD does not cover the following services.
A. Services classified as
				educational.
B. Services to non-MAP
				eligible individuals.
C. Services
				billed by a practitioner outside his or her area of expertise.
D. Vocational training that is related solely
				to specific employment opportunities, work skills or work settings.
E. Services that duplicate services billed
				outside the school setting unless determined to be medically necessary and MAD
				or its designee gave prior authorization for the service.
F. Services not identified in the eligible
				recipient's IEP, IFSP, 504 plan, IHCP or other care plan.
G. Transportation services listed below:
(1) transportation that a MAP eligible
				recipient would otherwise receive in the course of attending school;
(2) transportation for the eligible recipient
				with special education needs under the Individuals with Disabilities Education
				Act (IDEA) who rides the regular school bus to and from school with
				non-disabled children; and
(3)
				transportation of a minor aged child, such as a sibling of the eligible
				recipient who is simply accompanying the eligible recipient to a MAD
				service.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 320 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT) SERVICES › Part 6 - SCHOOL-BASED SERVICES FOR MAP ELIGIBLE RECIPIENTS UNDER TWENTY-ONE YEARS OF AGE › Section 8.320.6.16 - PRIOR AUTHORIZATION AND UTILIZATION REVIEW

Current through Register Vol. 35, No. 13, July 16, 2024
Certain procedures or services identified in the UR
				  instructions may require prior authorization from MAD or its designee. Services
				  for which prior authorization was obtained remain subject to UR at any point in
				  the payment process. All services are subject to UR for medical necessity and
				  program compliance. Reviews can be performed before services are furnished,
				  after services are furnished and before payment is made, or after payment is
				  made. When services are billed to and paid by a coordinated services contractor
				  authorized by HSD, the provider must follow that contractor's instructions for
				  authorization of services. A specific service may have additional prior
				  authorization requirements listed in the service's prior authorization section.
				  The prior authorization of a service does not guarantee that an individual is
				  eligible for a MAD service. A provider must verify that an individual is
				  eligible for a specific MAD service at the time the service is furnished and
				  must determine if the eligible recipient has other health insurance. A provider
				  who disagrees with the denial of a prior authorization request or other review
				  decision can request a reconsideration
.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 320 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT) SERVICES › Part 6 - SCHOOL-BASED SERVICES FOR MAP ELIGIBLE RECIPIENTS UNDER TWENTY-ONE YEARS OF AGE › Section 8.320.6.17 - REIMBURSEMENT

Current through Register Vol. 35, No. 13, July 16, 2024
Reimbursement to the LEA, REC, or SFEA is not contingent
				  upon billing a third party payer first when the eligible recipient has other
				  insurance. MAD is generally the payer of last resort. However, if medical
				  services are included in the eligible recipient's IEP, IFSP, 504 plan, IHCP or
				  other care plan, and an exception is created under 42 USE 1396b(c),
				  20 USC
				  1412(a)(12) and 34 CFR
				  300.142., and the services are otherwise covered by MAD, then MAD is authorized
				  to pay for such services. The LEA, REC, or other SFEA must submit claims for
				  reimbursement on the 837P electronic format or its successor unless it received
				  written permission from MAD to bill on paper.
A. Interim payment to the LEA, REC or other
				SFEA for covered services are made at the MAD fee schedule for the specific
				service.
B. The LEA, REC or other
				SFEA will complete an annual cost report utilized to reconcile interim payments
				with actual costs in accordance with CMS approved methodology. The LEA, REC or
				other SFEA must participate in the CMS approved quarterly random moment time
				study (RMTS).
C. A MAD school-based
				service that is in the eligible recipient's IEP, IFSP, 504 plan, IHCP or other
				care plan must only be billed by the school. When the school utilizes a
				contractor to render the service, the school must submit the claim, not the
				contractor. It is the responsibility of the school to reimburse the
				contractor.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 320 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT) SERVICES › Part 6 - SCHOOL-BASED SERVICES FOR MAP ELIGIBLE RECIPIENTS UNDER TWENTY-ONE YEARS OF AGE › Section 8.320.6.18 - REIMBURSEMENT

Current through Register Vol. 35, No. 13, July 16, 2024
Reimbursement to the LEA, REC, or SFEA is not contingent upon
				  billing a third party payer first when the MAP eligible recipient has other
				  insurance. MAD is generally the payer of last resort. However, if medical
				  services are included in the MAP eligible recipient's IEP or IFSP, and an
				  exception is created under 42 USE 1396b(c),
				  20 USC
				  1412(a)(12) and
				  34 CFR 300.142.,
				  and the services are otherwise covered by MAD, then MAD is authorized to pay
				  for such services. The LEA, REC, or other SFEA must submit claims for
				  reimbursement on the 837P electronic format or its successor unless it received
				  written permission from MAD to bill on paper. Reimbursement to the LEA, REC or
				  other SFEA for covered services billed by individual practitioners is made at
				  the MAD fee schedule for the specific service.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 321 - SPECIALIZED BEHAVIORAL HEALTH SERVICES › Part 2 - SPECIALIZED BEHAVIORAL HEALTH PROVIDER ENROLLMENT AND REIMBURSEMENT › Section 8.321.2.3 - STATUTORY AUTHORITY

Current through Register Vol. 35, No. 13, July 16, 2024
The New Mexico medicaid program and other health care
				  programs are administered pursuant to regulations promulgated by the federal
				  department of health and human services under Title XIX of the Social Security
				  Act as amended or by state statute. See Section
				  27-2-12
				  et seq., NMSA 1978.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 321 - SPECIALIZED BEHAVIORAL HEALTH SERVICES › Part 2 - SPECIALIZED BEHAVIORAL HEALTH PROVIDER ENROLLMENT AND REIMBURSEMENT › Section 8.321.2.5 - EFFECTIVE DATE

Current through Register Vol. 35, No. 13, July 16, 2024
August 10, 2021, unless a later date is cited at the end of a
				  section.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 321 - SPECIALIZED BEHAVIORAL HEALTH SERVICES › Part 2 - SPECIALIZED BEHAVIORAL HEALTH PROVIDER ENROLLMENT AND REIMBURSEMENT › Section 8.321.2.6 - OBJECTIVE

Current through Register Vol. 35, No. 13, July 16, 2024
The objective of these rules is to provide instruction for
				  the service portion of the New Mexico medical assistance programs
				  (MAP).
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 321 - SPECIALIZED BEHAVIORAL HEALTH SERVICES › Part 2 - SPECIALIZED BEHAVIORAL HEALTH PROVIDER ENROLLMENT AND REIMBURSEMENT › Section 8.321.2.8 - MISSION STATEMENT

Current through Register Vol. 35, No. 13, July 16, 2024
To transform lives. Working with our partners, we design and
				  deliver innovative, high quality health and human services that improve the
				  security and promote independence for New Mexicans in their
				  communities.