reglab/statecodes huggingface dataset:
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 2 - CASE MANAGEMENT SERVICES FOR ADULTS WITH DEVELOPMENTAL DISABILITIES › Section 8.326.2.10 - ELIGIBLE PROVIDERS

Current through Register Vol. 35, No. 13, July 16, 2024
A. Upon
				approval of New Mexico medical assistance program provider participation
				agreements by the New Mexico medical assistance division (MAD), the following
				agencies are eligible to be reimbursed for providing case management services:
(1) state agencies in New Mexico providing
				case management services to individuals with developmental
				disabilities;
(2) Indian tribal
				governments and Indian health service clinics; and
(3) community-based agencies in New Mexico
				that do not furnish adult day habilitation, work related services, or adult
				residential services to individuals with developmental disabilities.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 2 - CASE MANAGEMENT SERVICES FOR ADULTS WITH DEVELOPMENTAL DISABILITIES › Section 8.326.2.11 - PROVIDER RESPONSIBILITIES

Current through Register Vol. 35, No. 13, July 16, 2024
Providers who furnish services to medicaid recipients must
				  comply with all specified medicaid participation requirements. See 8.302.1
				  NMAC, General Provider Policies. Providers must verify that individuals are
				  eligible for medicaid at the time services are furnished and determine if
				  medicaid recipients have other health insurance. Providers must maintain
				  records which are sufficient to fully disclose the extent and nature of the
				  services furnished to recipients. See 8.302.1 NMAC, General Provider Policies.
				  Documentation must substantiate the date of service, type of contact, category
				  of case management service furnished, length/time units of service furnished,
				  nature/content of the service furnished, result of service or intended result
				  and relationship of the service furnished to goals identified in the plan of
				  care.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 2 - CASE MANAGEMENT SERVICES FOR ADULTS WITH DEVELOPMENTAL DISABILITIES › Section 8.326.2.12 - ELIGIBLE RECIPIENTS

Current through Register Vol. 35, No. 13, July 16, 2024
A. Case
				management services are available for eligible medicaid recipients that meet
				all of the following criteria:
(1) 21 years of
				age or older;
(2) resident of the
				state of New Mexico;
(3) meet the
				state definition of an individual with a developmental disability;
(4) placement on the list for developmental
				disability services by the community services team (CST) of the developmental
				disabilities division of the HCA;
(5) resides outside a medicaid certified
				intermediate care facility for the mentally retarded (ICF-MR); and
(6) not a participant in a home and community
				based services waiver program.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 2 - CASE MANAGEMENT SERVICES FOR ADULTS WITH DEVELOPMENTAL DISABILITIES › Section 8.326.2.13 - COVERED SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
Medicaid coverage for case management services varies by the
				  priority assigned recipients by the CST.
A. Case management services for recipients
				assigned a priority three: Case management services for recipients assigned a
				priority three are limited. Medicaid covers assessments of recipients' needs
				and the coordination and performance of evaluations and assessments. A
				follow-up is performed during the third month with appropriate recommendations.
				Medicaid covers case management services for recipients classified as priority
				three only for an initial 90 day period, unless the recipient's urgency of need
				priority changes to priority one or priority two.
B. Case management services for recipients
				assigned priority one or priority two: Medicaid covers case management services
				for those recipients assigned a priority one or priority two for up to 60 days
				after suitable placement or services are received. Medicaid covers the
				following case management service activities for these recipients:
(1) assessment of the recipient's medical and
				social needs and functional limitations;
(2) coordination and monitoring of
				evaluations and services;
(3) help
				in identifying available service providers and programs to enhance the
				recipient's community access and involvement, including:
(a) arrangement of transportation;
(b) location of housing;
(c) location of providers to teach living
				skills;
(d) location of vocational
				or educational services; and
(e)
				location of civic or recreational services, as needed.
(4) facilitation and participation in the
				development, review and evaluation of a plan of care and revision of that plan
				when warranted; and
(5) assessment
				of the recipient's progress and continued need for services.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 2 - CASE MANAGEMENT SERVICES FOR ADULTS WITH DEVELOPMENTAL DISABILITIES › Section 8.326.2.14 - NONCOVERED SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
Case management services are subject to the limitations and
				  coverage restrictions which exist for other medicaid services. See 8.301.3
				  NMAC, General Noncovered Services. Medicaid does not cover the following
				  specific activities:
A. services
				furnished to individuals who are not medicaid eligible or do not meet the
				definition of an eligible recipient for these case management
				services;
B. services furnished by
				case managers which are not substantiated with appropriate documentation in the
				recipient's file;
C. formal
				educational or vocational services which relate to traditional academic
				subjects or job training;
D.
				outreach activities to contact potential recipients, except as described under
				covered services;
E. all
				administrative activities conducted after the initial 90 day referral by the
				CST;
F. institutional discharge
				planning which must be furnished by the institution prior to
				discharge;
G. services which are
				furnished under other categories, such as therapies, transportation or
				counseling;
H. services which are
				considered by MAD or its designee to be excessive based on the condition of the
				recipient;
I. monitoring the
				quality of service provider agencies;
J. resource development; and
K. testifying before governmental bodies,
				such as city council meetings or legislative committees, even if on behalf of
				the recipient.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 2 - CASE MANAGEMENT SERVICES FOR ADULTS WITH DEVELOPMENTAL DISABILITIES › Section 8.326.2.15 - PLAN OF CARE

Current through Register Vol. 35, No. 13, July 16, 2024
A. Case
				managers develop and implement plans of care (POC) based on standards developed
				by the developmental disabilities division of the HCA. For purposes of
				compliance with medicaid regulations, the following must be contained in the
				plan of care or documents used to develop the plan of care. The plan of care
				and supporting documents must be available for review in the recipient's file:
(1) statement of the nature of the specific
				problem and needs of the recipient;
(2) description of the functional level of
				the recipient, including an assessment and evaluation of the following:
(a) mental status assessment;
(b) intellectual function
				assessment;
(c) psychological
				assessment;
(d) educational
				assessment;
(e) vocational
				assessment;
(f) social
				assessment;
(g) medication
				assessment; and
(h) physical
				assessment.
(3)
				description of the intermediate and long-range goals and placement options with
				the projected timetable for their attainment, including information on the
				duration and scope of services; and
(4) statement and rationale of the plan of
				treatment for achieving these intermediate and long-range goals, including
				review and modification of the plan.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 2 - CASE MANAGEMENT SERVICES FOR ADULTS WITH DEVELOPMENTAL DISABILITIES › Section 8.326.2.16 - PRIOR APPROVAL AND UTILIZATION REVIEW

Current through Register Vol. 35, No. 13, July 16, 2024
All medicaid services 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 Approval and
				  Utilization Review. Once enrolled, providers receive instructions and
				  documentation forms necessary for prior approval and claims processing.
A. Prior approval: Certain procedures or
				services which are part of the recipients' plan of care can require prior
				approval from MAD or its designee. Services for which prior approval was
				obtained remain subject to utilization review at any point in the payment
				process.
B. Eligibility
				determination: Prior approval of services does not guarantee that individuals
				are eligible for medicaid. Providers must verify that individuals are 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 approval request denials or other review decisions can request a
				rereview and a reconsideration. See 8.350.2 NMAC, Reconsideration of
				Utilization Review Decisions.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 2 - CASE MANAGEMENT SERVICES FOR ADULTS WITH DEVELOPMENTAL DISABILITIES › Section 8.326.2.17 - REIMBURSEMENT

Current through Register Vol. 35, No. 13, July 16, 2024
A. Case management
				providers must submit claims for reimbursement on the HCFA-1500 claim form or
				its successor. See 8.302.2 NMAC, Billing for Medicaid Services. Instructions on
				documentation, billing and claims processing are sent to approved medicaid
				providers. Reimbursement for covered case management services is made at the
				lesser of the following:
(1) the provider's
				billed charge; or
(2) the MAD fee
				schedule for the specific service or procedure.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 3 - CASE MANAGEMENT SERVICES FOR PREGNANT INDIVIDUALS AND THEIR INFANTS › Section 8.326.3.3 - STATUTORY AUTHORITY

Current through Register Vol. 35, No. 13, July 16, 2024
The New Mexico medicaid program is administered pursuant to
				  regulations promulgated by the federal department of health and human services
				  under Title XIX of the Social Security Act, as amended and by the state health
				  care authority pursuant to state statute. See Sections 27-2-12 et seq. NMSA
				  1978 (Repl. Pamp. 1991). 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 326 - CASE MANAGEMENT SERVICES › Part 3 - CASE MANAGEMENT SERVICES FOR PREGNANT INDIVIDUALS AND THEIR INFANTS › Section 8.326.3.6 - OBJECTIVE

Current through Register Vol. 35, No. 13, July 16, 2024
The objective of these regulations is to provide policies for
				  the service portion of the New Mexico medicaid program. These policies describe
				  eligible providers, covered services, noncovered services, utilization review,
				  and provider reimbursement.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 3 - CASE MANAGEMENT SERVICES FOR PREGNANT INDIVIDUALS AND THEIR INFANTS › Section 8.326.3.8 - 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 326 - CASE MANAGEMENT SERVICES › Part 3 - CASE MANAGEMENT SERVICES FOR PREGNANT INDIVIDUALS AND THEIR INFANTS › Section 8.326.3.9 - CASE MANAGEMENT SERVICES FOR PREGNANT INDIVIDUALS AND THEIR INFANTS

Current through Register Vol. 35, No. 13, July 16, 2024
The New Mexico medical assistance program (medicaid) pays for
				  medically necessary health services furnished to eligible recipients, including
				  case management services furnished to medicaid eligible pregnant individuals on
				  the day the pregnancy ends through the last day in which the 12-month
				  postpartum period ends. This part describes eligible providers, eligible
				  recipients, covered services, service limitations and general reimbursement
				  methodology.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 3 - CASE MANAGEMENT SERVICES FOR PREGNANT INDIVIDUALS AND THEIR INFANTS › Section 8.326.3.10 - Eligible Providers

Current through Register Vol. 35, No. 13, July 16, 2024
A. Upon
				approval of New Mexico medical assistance program provider participation
				agreements by the New Mexico medical assistance division (MAD), the following
				certified agencies are eligible to be reimbursed for furnishing case management
				services to eligible pregnant individuals and their infants:
(1) public health offices of the New Mexico
				department of health;
(2) Indian
				tribal governments or Indian health services;
(3) federally qualified health centers
				(FQHC); and
(4) other
				community-based agencies which meet the requirements for
				participation.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 3 - CASE MANAGEMENT SERVICES FOR PREGNANT INDIVIDUALS AND THEIR INFANTS › Section 8.326.3.11 - PROVIDER RESPONSIBILITIES

Current through Register Vol. 35, No. 13, July 16, 2024
Providers who furnish services to medicaid recipients must
				  comply with all specified medicaid participation requirements. See 8.302.1
				  NMAC,
General Provider Policies
. Providers must verify that
				  individuals are eligible for medicaid at the time services are furnished and
				  determine if medicaid recipients have other health insurance. Providers must
				  maintain records which are sufficient to fully disclose the extent and nature
				  of the services furnished to recipients. See 8.302.1 NMAC,
General
				  Provider Policies
. Documentation must substantiate the date of
				  service, type of contact, category of case management service furnished,
				  length/time units of service furnished, nature/content of the service
				  furnished, result of service or intended result and relationship of the service
				  furnished to goals identified in the individual service plan.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 3 - CASE MANAGEMENT SERVICES FOR PREGNANT INDIVIDUALS AND THEIR INFANTS › Section 8.326.3.12 - Eligible Recipients

Current through Register Vol. 35, No. 13, July 16, 2024
Case management services are available to medicaid eligible
				  pregnant individuals and their infants up to 12-months following the delivery
				  in accordance with 8.291.400.14 NMAC.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 3 - CASE MANAGEMENT SERVICES FOR PREGNANT INDIVIDUALS AND THEIR INFANTS › Section 8.326.3.13 - Covered Services and Service Limitations

Current through Register Vol. 35, No. 13, July 16, 2024
Medicaid covers case management services for pregnant
				  individuals and their infants which help recipients gain access to medical,
				  social, educational or other needed services. Case management services provide
				  necessary coordination with providers of non-medical services, such as
				  nutrition or education programs, when these services are necessary to enable
				  recipients to benefit from the health services paid for by medicaid.
A. Medicaid covers the following case
				management service activities furnished to pregnant individuals:
(1) identification of programs appropriate
				for the recipient's needs, including those which teach basic maternal and child
				health skills;
(2) help in
				accessing the identified programs;
(3) assessment of the service needs of
				recipients to coordinate the delivery of services when multiple providers or
				programs are involved in the provision of care;
(4) reassessment to ensure that the services
				which were obtained are necessary and appropriate in meeting the recipient's
				needs; and
(5) determination of
				whether any additional services are warranted.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 3 - CASE MANAGEMENT SERVICES FOR PREGNANT INDIVIDUALS AND THEIR INFANTS › Section 8.326.3.14 - NONCOVERED SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
Case management services are subject to the limitations and
				  coverage restrictions which exist for other medicaid services. See 8.301.3
				  NMAC,
General Noncovered Services
. Medicaid does not cover the
				  following specific activities:
A.
				services furnished to individuals who are not medicaid eligible, who are not
				pregnant, or who are not residents of New Mexico;
B. services furnished by case managers which
				are not substantiated with appropriate documentation in the recipient's
				file;
C. formal educational or
				vocational services which are related to traditional academic subjects or job
				training;
D. outreach and
				identification activities in which providers attempt to contact potential
				recipients;
E. administrative
				activities, such as medicaid eligibility determinations and intake
				processing;
F. institutional
				discharge planning;
G. services
				which are furnished by other practitioners, such as therapies, transportation
				and homemaker or personal care services; and
H. services considered by MAD or its designee
				to be excessive based on the needs of the recipient and on the documentation by
				the case manager.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 3 - CASE MANAGEMENT SERVICES FOR PREGNANT INDIVIDUALS AND THEIR INFANTS › Section 8.326.3.15 - Plan of Care

Current through Register Vol. 35, No. 13, July 16, 2024
A. Case
				managers develop and implement plans of care for each medicaid recipient. Plans
				of care are developed in consultation with the recipients, families or legal
				guardian(s), physicians and others involved with care.
B. The following must be contained in the
				plan of care or documents used in the development of the plan of care. The plan
				of care and all supporting documentation must be available for review in the
				recipient's file:
(1) statement of the nature
				of the specific problem and needs of the woman or infant;
(2) description of the intermediate and
				long-range goals with the projected timetable for their attainment, including
				specific information on the duration and scope of services; and
(3) statement and rationale of the plan of
				treatment for achieving these intermediate and long-range goals, including
				review and modification of the plan.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 3 - CASE MANAGEMENT SERVICES FOR PREGNANT INDIVIDUALS AND THEIR INFANTS › Section 8.326.3.16 - PRIOR APPROVAL AND UTILIZATION REVIEW

Current through Register Vol. 35, No. 13, July 16, 2024
All medicaid services 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 approval and claims
				  processing.
A.
Prior
				approval:
Certain procedures or services which are part of the treatment
				plan can require prior approval from MAD or its designee. See utilization
				instruction for those services. Services for which prior approval was obtained
				remain subject to utilization review at any point in the payment
				process.
B.
Eligibility
				determination:
Prior approval of services does not guarantee that
				individuals are eligible for medicaid. Providers must verify that individuals
				are 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 approval request denials or other review decisions can
				request a re-review and a reconsideration. See Section MAD-953,
Reconsideration of Utilization Review Decisions
.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 3 - CASE MANAGEMENT SERVICES FOR PREGNANT INDIVIDUALS AND THEIR INFANTS › Section 8.326.3.17 - REIMBURSEMENT

Current through Register Vol. 35, No. 13, July 16, 2024
A. Case management
				providers must submit claims for reimbursement on the HCFA 1500 claim form or
				its successor. See 8.302.2 NMAC,
Billing for Medicaid
				Services
. Instructions on documentation, billing and claims processing
				are sent to approved medicaid providers. Reimbursement for case management
				services is made at the lesser of the following:
(1) the provider's billed charge;
				or
(2) the MAD fee schedule for the
				specific service or procedure.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 4 - CASE MANAGEMENT SERVICES FOR THE CHRONICALLY MENTALLY ILL › Section 8.326.4.3 - STATUTORY AUTHORITY

Current through Register Vol. 35, No. 13, July 16, 2024
The New Mexico medicaid program is administered pursuant to
				  regulations promulgated by the federal department of health and human services
				  under Title XIX of the Social Security Act, as amended and by the state
				  pursuant to state statute. See Section 27-2-12 et seq. NMSA 1978 (Repl. Pamp.
				  1991). 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 326 - CASE MANAGEMENT SERVICES › Part 4 - CASE MANAGEMENT SERVICES FOR THE CHRONICALLY MENTALLY ILL › Section 8.326.4.6 - OBJECTIVE

Current through Register Vol. 35, No. 13, July 16, 2024
The objective of these regulations is to provide policies for
				  the service portion of the New Mexico medicaid program. These policies describe
				  eligible providers, covered services, noncovered services, utilization review,
				  and provider reimbursement.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 4 - CASE MANAGEMENT SERVICES FOR THE CHRONICALLY MENTALLY ILL › Section 8.326.4.8 - MISSION STATEMENT

Current through Register Vol. 35, No. 13, July 16, 2024
The mission of the New Mexico medical assistance division
				  (MAD) is to maximize the health status of medicaid-eligible individuals by
				  furnishing payment for quality health services at levels comparable to private
				  health plans.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 4 - CASE MANAGEMENT SERVICES FOR THE CHRONICALLY MENTALLY ILL › Section 8.326.4.9 - CASE MANAGEMENT SERVICES FOR THE CHRONICALLY MENTALLY ILL

Current through Register Vol. 35, No. 13, July 16, 2024
The New Mexico medical assistance program (medicaid) pays for
				  medically necessary health services furnished to eligible recipients for case
				  management services furnished to recipients who are chronically mentally ill [
				  42 U.S.C. Section
				  1396 n(g)(1)(2) ]. This part describes
				  eligible providers, eligible recipients, covered services, service restrictions
				  and general reimbursement methodology.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 4 - CASE MANAGEMENT SERVICES FOR THE CHRONICALLY MENTALLY ILL › Section 8.326.4.10 - ELIGIBLE PROVIDERS

Current through Register Vol. 35, No. 13, July 16, 2024
A. Upon
				approval of New Mexico medical assistance program provider participation
				agreements by the New Mexico medical assistance division (MAD), the following
				agencies are reimbursed for furnishing case management services to recipients
				who are chronically mentally ill:
(1)
				community mental health centers funded by the mental health division of the
				department of health;
(2) Indian
				tribal governments; and
(3) other
				community-based agencies which have demonstrated direct experience in case
				management services and success in serving the target population, as certified
				by the department of health.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 4 - CASE MANAGEMENT SERVICES FOR THE CHRONICALLY MENTALLY ILL › Section 8.326.4.11 - PROVIDER RESPONSIBILITIES

Current through Register Vol. 35, No. 13, July 16, 2024
Providers who furnish services to medicaid recipients must
				  comply with all specified medicaid participation requirements. See 8.302.1
				  NMAC,
General Provider Policies
. Providers must verify that
				  individuals are eligible for medicaid at the time services are furnished and
				  determine if medicaid recipients have other health insurance. Providers must
				  maintain records which are sufficient to fully disclose the extent and nature
				  of the services furnished to recipients. See 8.302.1 NMAC,
General
				  Provider Policies
. Documentation must substantiate the date of
				  service, type of contact, category of case management service furnished,
				  length/time units of service furnished, nature/content of the service
				  furnished, result of service or intended result, and relationship of the
				  service furnished to goals identified in the plan of care.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 4 - CASE MANAGEMENT SERVICES FOR THE CHRONICALLY MENTALLY ILL › Section 8.326.4.12 - ELIGIBLE RECIPIENTS

Current through Register Vol. 35, No. 13, July 16, 2024
Medicaid covers case management services furnished to
				  medicaid recipients who are chronically mentally ill and who are not residents
				  of an institution for mental disease. Chronic mental illness is defined by
				  diagnosis, disability and duration. The major diagnoses include schizophrenia,
				  affective disorders, bipolar disorders, and serious personality disorders, such
				  as borderline personality. The illness must be of a duration of more than one
				  year and cause serious impairment of functions relative to daily
				  living.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 4 - CASE MANAGEMENT SERVICES FOR THE CHRONICALLY MENTALLY ILL › Section 8.326.4.13 - COVERED SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
Medicaid covers the following case management service
				  activities for recipients who are chronically mentally ill:
A. assessment of the recipient's medical and
				social needs and functional limitations using standardized needs assessment
				instruments;
B. development and
				implementation of individualized plan of care;
C. mobilizing the use of "natural helping"
				networks, such as family members, church members and friends;
D. development of increased opportunities for
				community access and involvement including assistance in the location of
				housing, community living skills, teaching, vocational, civil and recreational
				service programs;
E. coordination
				and monitoring of the delivery of services; and
F. evaluation of the effectiveness of
				services furnished under the plan of care and revision of the plan as
				conditions warrant.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 4 - CASE MANAGEMENT SERVICES FOR THE CHRONICALLY MENTALLY ILL › Section 8.326.4.14 - NONCOVERED SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
Case management services are subject to the limitations and
				  coverage restrictions which exist for other medicaid services. See 8.301.3
				  NMAC,
General Noncovered Services
. Medicaid does not cover the
				  following specific activities:
A.
				services furnished to individuals who are not medicaid eligible or who are not
				eligible for these services;
B.
				services furnished by case managers which are not substantiated with
				appropriate documentation in the recipient's file;
C. formal educational or vocational services
				related to traditional academic subjects or job training;
D. outreach and identification activities in
				which providers attempt to contact potential recipients;
E. administrative activities, such as
				medicaid eligibility determinations and intake processing;
F. institutional discharge
				planning;
G. services which are
				furnished under other categories, such as therapies, transportation or
				counseling; or
H. services
				considered by MAD or its designee to be excessive based on the needs of
				recipient and documentation in the case management file.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 4 - CASE MANAGEMENT SERVICES FOR THE CHRONICALLY MENTALLY ILL › Section 8.326.4.15 - PLAN OF CARE

Current through Register Vol. 35, No. 13, July 16, 2024
A. Case
				managers develop and implement plans of care in conjunction with the
				recipients, families or legal guardian(s), therapists, physicians, or others
				who assist with the recipient's care.
B. The following must be contained in the
				plan of care or documents used in the development of the plan of care. The plan
				of care and all supporting documentation must be available for review in the
				recipient's file:
(1) statement of the nature
				of the specific problem and the specific needs of the recipient;
(2) description of the functional level of
				the recipient, including an assessment and evaluation of the following:
(a) mental status assessment;
(b) intellectual function
				assessment;
(c) psychological
				assessment;
(d) educational
				assessment;
(e) vocational
				assessment;
(f) social
				assessment;
(g) medication
				assessment; and
(h) physical
				assessment.
(3)
				description of the intermediate and long-range goals with the projected
				timetable for their attainment, including information about the duration and
				scope of services;
(4) statement
				and rationale of the plan of treatment for achieving these intermediate and
				long-range goals, including review and modification of the plan.
(5) the plan of care must be retained by
				agency providers and available for utilization review purposes; plans of care
				must be updated and revised, as indicated, at least every six (6) months or
				more often, as indicated by the recipient's condition.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 4 - CASE MANAGEMENT SERVICES FOR THE CHRONICALLY MENTALLY ILL › Section 8.326.4.16 - PRIOR APPROVAL AND UTILIZATION REVIEW

Current through Register Vol. 35, No. 13, July 16, 2024
All medicaid services 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 approval and claims
				  processing.
A.
Prior
				approval:
Certain procedures or services which are part of the plan of
				care can require prior approval from MAD or its designee. See utilization
				instructions for the specific service. Services for which prior approval was
				obtained remain subject to utilization review at any point in the payment
				process.
B.
Eligibility
				determination:
Prior approval of services does not guarantee that
				individuals are eligible for medicaid. Providers must verify that individuals
				are 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 approval request denials or other review decisions can
				request a re-review and a reconsideration. See Section MAD-953,
Reconsideration of Utilization Review Decisions
.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 4 - CASE MANAGEMENT SERVICES FOR THE CHRONICALLY MENTALLY ILL › Section 8.326.4.17 - REIMBURSEMENT

Current through Register Vol. 35, No. 13, July 16, 2024
A. Case management
				providers must submit claims for reimbursement on the HCFA 1500 claim form or
				its successor. See 8.302.2 NMAC,
Billing for Medicaid
				Services
. Instructions on documentation, billing and claims processing
				are sent to approved medicaid providers. Reimbursement for case management
				services is made at the lesser of the following:
(1) the provider's billed charge;
				or
(2) the MAD fee schedule for the
				specific service or procedure.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 5 - CASE MANAGEMENT SERVICES FOR TRAUMATICALLY BRAIN INJURED ADULTS › Section 8.326.5.3 - STATUTORY AUTHORITY

Current through Register Vol. 35, No. 13, July 16, 2024
The New Mexico medicaid program is administered pursuant to
				  regulations promulgated by the federal department of health and human services
				  under Title XIX of the Social Security Act, as amended and by the state health
				  care authority pursuant to state statute. See Section 27-2-12 et seq. NMSA 1978
				  (Repl. Pamp. 1991). 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 326 - CASE MANAGEMENT SERVICES › Part 5 - CASE MANAGEMENT SERVICES FOR TRAUMATICALLY BRAIN INJURED ADULTS › Section 8.326.5.6 - OBJECTIVE

Current through Register Vol. 35, No. 13, July 16, 2024
The objective of these regulations is to provide policies for
				  the service portion of the New Mexico medicaid program. These policies describe
				  eligible providers, covered services, noncovered services, utilization review,
				  and provider reimbursement.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 5 - CASE MANAGEMENT SERVICES FOR TRAUMATICALLY BRAIN INJURED ADULTS › Section 8.326.5.8 - MISSION STATEMENT

Current through Register Vol. 35, No. 13, July 16, 2024
The mission of the New Mexico medical assistance division
				  (MAD) is to maximize the health status of medicaid-eligible individuals by
				  furnishing payment for quality health services at levels comparable to private
				  health plans.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 5 - CASE MANAGEMENT SERVICES FOR TRAUMATICALLY BRAIN INJURED ADULTS › Section 8.326.5.9 - CASE MANAGEMENT SERVICES FOR TRAUMATICALLY BRAIN INJURED ADULTS

Current through Register Vol. 35, No. 13, July 16, 2024
The New Mexico medicaid program (medicaid) pays for medically
				  necessary health services furnished to eligible recipients, including covered
				  case management services furnished to adult recipients who are traumatically
				  brain injured [
				  42 U.S.C. Section
				  1396 n(g)(1)(2) ]. This part describes
				  eligible providers, eligible recipients, covered services, service limitations
				  and general reimbursement methodology.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 5 - CASE MANAGEMENT SERVICES FOR TRAUMATICALLY BRAIN INJURED ADULTS › Section 8.326.5.10 - ELIGIBLE PROVIDERS

Current through Register Vol. 35, No. 13, July 16, 2024
A. Upon
				approval of New Mexico medical assistance program provider participation
				agreements by the New Mexico medical assistance division (MAD), the following
				agencies are eligible for certification as case management agencies:
(1) government or community agencies which
				meet certification standards developed by MAD or its designee;
(2) Indian tribal governments;
(3) Indian health services; and
(4) federally qualified health centers
				(FQHC).
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 5 - CASE MANAGEMENT SERVICES FOR TRAUMATICALLY BRAIN INJURED ADULTS › Section 8.326.5.11 - PROVIDER RESPONSIBILITIES

Current through Register Vol. 35, No. 13, July 16, 2024
Providers who furnish services to medicaid recipients must
				  comply with all specified medicaid participation requirements. See 8.302.1
				  NMAC,
General Provider Policies
.
A. Providers must verify that individuals are
				eligible for medicaid at the time services are furnished and determine if
				medicaid recipients have other health insurance.
B. Providers must maintain records which are
				sufficient to fully disclose the extent and nature of the services furnished to
				recipients. See 8.302.1 NMAC,
General Provider
				Policies
.
C. Documentation
				must substantiate the date of service, type of contact, category of case
				management service furnished, length/time units of service furnished,
				nature/content of the service furnished, result of service of intended result
				and relationship of the service furnished to goals identified in the individual
				plan of care.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 5 - CASE MANAGEMENT SERVICES FOR TRAUMATICALLY BRAIN INJURED ADULTS › Section 8.326.5.12 - ELIGIBLE INDIVIDUALS

Current through Register Vol. 35, No. 13, July 16, 2024
A. Case
				management services are available for eligible medicaid recipients who meet all
				of the following criteria:
(1) twenty-one
				(21) years of age or older;
(2)
				resident of the state of New Mexico;
(3) resident of Santa Fe, Chavez, Dona Ana,
				San Juan, McKinley or San Miguel counties;
(4) suffer from traumatic brain injury;
				and
(5) reside outside an
				institution.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 5 - CASE MANAGEMENT SERVICES FOR TRAUMATICALLY BRAIN INJURED ADULTS › Section 8.326.5.13 - COVERED SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
Medicaid covers those case management services for traumatic
				  brain-injured adults which are medically necessary to help these recipients
				  gain access to needed medical, social, educational and other services. Medicaid
				  covers the following specific case management services:
A. identification of programs which are
				appropriate for a recipient's needs and provision of assistance to the
				recipient in accessing those programs;
B. assessment of the service needs of
				recipients to coordinate the delivery of services if multiple providers or
				programs are involved in the provision of care; and
C. reassessment to ensure that the services
				obtained are medical necessary and appropriate to meet the recipient's
				needs.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 5 - CASE MANAGEMENT SERVICES FOR TRAUMATICALLY BRAIN INJURED ADULTS › Section 8.326.5.14 - NONCOVERED SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
Case management services are subject to the limitations and
				  coverage restrictions which exist for other medicaid services. See 8.301.3
				  NMAC,
General Noncovered Services
. Medicaid does not cover the
				  following specific activities:
A.
				services furnished to individuals who are not medicaid-eligible, who do not
				meet the definition of traumatically brain injured, or who are not residents of
				Santa Fe county or the state of New Mexico;
B. services furnished by case managers which
				are not substantiated with appropriate documentation in the recipient's
				file;
C. daily independent living
				skills training;
D. outreach and
				identification activities in which providers attempt to contact potential
				recipients;
E. administrative
				activities, such as medicaid eligibility determinations and intake
				processing;
F. institutional
				discharge planning: if recipients are in medical institutions, medicaid covers
				case management only for the thirty (30) days prior to discharge; this service
				cannot duplicate required discharge planning activities conducted by medical
				institutions;
G. actual provision
				of services or treatment identified in the case management assessment;
				or
H. services furnished by other
				practitioners, such as therapies, transportation, homemaker or personal care
				services or psycho-social rehabilitation services.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 5 - CASE MANAGEMENT SERVICES FOR TRAUMATICALLY BRAIN INJURED ADULTS › Section 8.326.5.15 - PLAN OF CARE

Current through Register Vol. 35, No. 13, July 16, 2024
A. Case
				managers develop and implement individualized plans of care in consultation
				with recipients, families or legal guardians, physicians and others involved in
				the care.
B. The following must be
				contained in the plan of care or documents used in the development of the plan
				of care. The plan of care and all supporting documentation must be available
				for review in the recipient's file:
(1)
				statement of the nature of the specific problem and needs of the
				recipients;
(2) description of the
				functional level of the recipient, including an assessment and evaluation of
				the following:
(a) mental status
				assessment;
(b) intellectual
				function assessment;
(c)
				psychological assessment;
(d)
				educational assessment;
(e)
				vocational assessment;
(f) social
				assessment;
(g) medication
				assessment; and
(h) physical
				assessment.
(3)
				description of the intermediate and long-range goals, with the projected
				timetable for their attainment, including information on the duration and scope
				of services; and
(4) statement and
				rationale of the plan of care for achieving these intermediate and long-range
				goals, including review and modification of the plan;
(5) the plan of care must be retained by
				agency providers and available for utilization review purposes; plans of care
				must be updated and revised, at least every six (6) months or more often, as
				indicated by the recipient's condition.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 5 - CASE MANAGEMENT SERVICES FOR TRAUMATICALLY BRAIN INJURED ADULTS › Section 8.326.5.16 - PRIOR APPROVAL AND UTILIZATION REVIEW

Current through Register Vol. 35, No. 13, July 16, 2024
All medicaid services 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 approval and claims
				  processing.
A.
Prior
				approval:
Certain procedures or services which are a part of the plan of
				care can require prior approval from MAD or its designee. See utilization
				instructions for the specific service. Services for which prior approval was
				obtained remain subject to utilization review at any point in the payment
				process.
B.
Eligibility
				determination:
Prior approval of services does not guarantee that
				individuals are eligible for medicaid. Providers must verify that individuals
				are 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 approval request denials or other review decisions can
				request a re-review and a reconsideration. See Section MAD-953,
Reconsideration of Utilization Review Decisions
.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 5 - CASE MANAGEMENT SERVICES FOR TRAUMATICALLY BRAIN INJURED ADULTS › Section 8.326.5.17 - REIMBURSEMENT

Current through Register Vol. 35, No. 13, July 16, 2024
A. Case management
				providers must submit claims for reimbursement on the HCFA-1500 claim form or
				its successor. See 8.302.2 NMAC,
Billing for Medicaid
				Services
. Instructions on documentation, billing and claims processing
				are sent to approved medicaid providers. Reimbursement for case management
				services is made at the lesser of the following:
(1) the provider's billed charge;
				or
(2) the MAD fee schedule for the
				specific service.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 6 - CASE MANAGEMENT SERVICES FOR CHILDREN UP TO AGE THREE › Section 8.326.6.3 - STATUTORY AUTHORITY

Current through Register Vol. 35, No. 13, July 16, 2024
The New Mexico medicaid program is administered pursuant to
				  regulations promulgated by the federal department of health and human services
				  under Title XIX of the Social Security Act, as amended and by the state health
				  care authority pursuant to state statute. See Section 27-2-12 et seq. NMSA 1978
				  (Repl. Pamp. 1991). 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 326 - CASE MANAGEMENT SERVICES › Part 6 - CASE MANAGEMENT SERVICES FOR CHILDREN UP TO AGE THREE › Section 8.326.6.6 - OBJECTIVE

Current through Register Vol. 35, No. 13, July 16, 2024
The objective of these regulations is to provide policies for
				  the service portion of the New Mexico medicaid program. These policies describe
				  eligible providers, covered services, noncovered services, utilization review,
				  and provider reimbursement.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 6 - CASE MANAGEMENT SERVICES FOR CHILDREN UP TO AGE THREE › Section 8.326.6.8 - MISSION STATEMENT

Current through Register Vol. 35, No. 13, July 16, 2024
The mission of the New Mexico medical assistance division
				  (MAD) is to maximize the health status of medicaid-eligible individuals by
				  furnishing payment for quality health services at levels comparable to private
				  health plans.