reglab/statecodes huggingface dataset:
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 324 - ADJUNCT SERVICES › Part 5 - VISION APPLIANCES, HEARING APPLIANCES, DURABLE MEDICAL EQUIPMENT, OXYGEN, MEDICAL SUPPLIES, PROSTHETICS AND ORTHOTICS › Section 8.324.5.16 - REIMBURSEMENT

Current through Register Vol. 35, No. 13, July 16, 2024
Once enrolled, a provider receives instructions on how to
				  access documentation, billing, and claims processing. Reimbursement to a
				  provider for covered 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.
A. The provider's billed
				charge must be his or her usual and customary charge for services.
B. "Usual and customary charge" refers to the
				amount which the individual provider charges the general public in the majority
				of cases for a specific procedure or service.
C.
Vision appliances:
A vision
				service provider, except an IHS facility, must submit claims for reimbursement
				on the CMS 1500 claim form or its successor.
D.
Hearing appliances:
A hearing
				aid or related service provider must submit claims for reimbursement on the CMS
				1500 claim form or its successor. Reimbursement for hearing aids is made at the
				lesser of the provider's billed charge, at the cost to the billing provider as
				indicated by the manufacturer's, the distributor's or wholesaler's invoice,
				which shall not exceed MAD's maximum reimbursement limitation amounts.
(1) Reimbursement for rental of hearing aids
				includes the following:
(a) rental charge for
				hearing aid; and
(b) hearing aid
				mold and batteries.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 324 - ADJUNCT SERVICES › Part 5 - VISION APPLIANCES, HEARING APPLIANCES, DURABLE MEDICAL EQUIPMENT, OXYGEN, MEDICAL SUPPLIES, PROSTHETICS AND ORTHOTICS › Section 8.324.5.17 - REIMBURSEMENT OF DME, MEDICAL SUPPLIES AND NUTRITIONAL PRODUCTS

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Reimbursement for purchase or rental:
Unless otherwise specified
				in this section, the provider's billed charges must be the usual and customary
				charge for the item or service. The term "usual and customary charge" refers to
				the amount that the individual provider charges the general public in the
				majority of cases for a specific item or service. Reimbursement for DME,
				medical supplies and nutritional products is made at the lesser of:
(1) the provider's billed charges or the MAD
				fee schedule; or
(2) when there is
				no applicable MAD fee schedule, payment is limited to the provider's
				acquisition invoice cost plus a percentage, as follows.
(a) DME, medical supplies and nutritional
				products:
(i) items for which the provider's
				actual acquisition cost, reflecting all discounts and rebates, is less than
				$1,000, payment is limited to the provider's actual acquisition cost plus 20
				percent;
(ii) items for which the
				provider's actual acquisition cost, reflecting all discounts and rebates, is
				$1,000 or greater, payment is limited to the provider's actual acquisition cost
				plus 10 percent;
(b) for
				a custom specialized wheelchair and its customized related accessories, payment
				is limited to the provider's actual acquisition cost plus 15 percent.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 324 - ADJUNCT SERVICES › Part 5 - VISION APPLIANCES, HEARING APPLIANCES, DURABLE MEDICAL EQUIPMENT, OXYGEN, MEDICAL SUPPLIES, PROSTHETICS AND ORTHOTICS › Section 8.324.5.18 - REIMBURSEMENT FOR PROSTHETICS AND ORTHOTICS

Current through Register Vol. 35, No. 13, July 16, 2024
A. A prosthetic and orthotic service provider
				must submit claims for reimbursement on the CMS-1500 claim form or its
				successor. Reimbursement for repairs made by the=]\ provider is made at the
				actual repair cost plus 50 percent. Repairs made by the manufacturer are
				reimbursed to the provider at the actual manufacturer's repair cost plus a
				handling fee of $20. If complications in securing the manufacturer's repair
				cause the provider to incur handling costs exceeding the predetermined amount
				established by MAD, the billing provider can be reimbursed for actual handling
				costs incurred if these actual costs are adequately documented. Reimbursement
				for additional accessories and supplies is made at the lower of the actual cost
				of the supply or accessory or the MAD fee schedule for the particular
				item.
B.
Reimbursement
				limitations:
The amount billed for the item includes all minor
				attachments, adjustments, additions, modifications, fittings and other services
				necessary to make the device functional. These items cannot be billed
				separately.
(1) MAD does not cover an
				additional charge for a hospital visit or home visit if fittings or
				measurements take place away from the provider's office.
(a) If the place of service is outside the
				provider's city limits, mileage can be billed for travel to the place of
				service.
(b) A prosthetic or
				orthotic device for a MAP eligible recipient hospitalized in a diagnostic
				related group (DRG) reimbursed hospital is reimbursed by the DRG methods
				described in 8.311.3 NMAC.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 324 - ADJUNCT SERVICES › Part 7 - TRANSPORTATION SERVICES AND LODGING › Section 8.324.7.3 - 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 324 - ADJUNCT SERVICES › Part 7 - TRANSPORTATION SERVICES AND LODGING › Section 8.324.7.6 - OBJECTIVE

Current through Register Vol. 35, No. 13, July 16, 2024
The objective of this rule 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 324 - ADJUNCT SERVICES › Part 7 - TRANSPORTATION SERVICES AND LODGING › Section 8.324.7.8 - MISSION STATEMENT

Current through Register Vol. 35, No. 13, July 16, 2024
To reduce the impact of poverty on people living in New
				  Mexico by providing support services that help families break the cycle of
				  dependency on public assistance.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 324 - ADJUNCT SERVICES › Part 7 - TRANSPORTATION SERVICES AND LODGING › Section 8.324.7.9 - TRANSPORTATION SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
The New Mexico medical assistance division (MAD) covers
				  expenses for transportation and other related expenses that MAD or its
				  coordinated services contractor determines are necessary to secure covered
				  medical and behavioral health examinations and treatment for a medical
				  assistance program (MAP) eligible recipient in or out of his or her home
				  community [
				  42
				  CFR Section 440.170 ]. Travel expenses
				  include the cost of transportation by long distance common carriers, taxicab,
				  handivan, and ground or air ambulance, all as appropriate to the situation and
				  location of the MAP eligible recipient. Related travel expenses include the
				  cost of meals and lodging made necessary by receipt of medical or behavioral
				  health care away from the MAP eligible recipient's home community. When
				  medically necessary, MAD covers similar expenses for an attendant who
				  accompanies the MAP eligible recipient to the medical or behavioral health
				  examination or treatment.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 324 - ADJUNCT SERVICES › Part 7 - TRANSPORTATION SERVICES AND LODGING › Section 8.324.7.11 - 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
				the New Mexico MAD administrative code (NMAC) rules, and 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 determining 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. MAD services furnished must be within the
				scope of practice defined by the provider's licensing board, scope of practice
				act, or regulatory authority. See 8.302.1 NMAC.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 324 - ADJUNCT SERVICES › Part 7 - TRANSPORTATION SERVICES AND LODGING › Section 8.324.7.12 - COVERED SERVICES AND SERVICE LIMITATIONS

Current through Register Vol. 35, No. 13, July 16, 2024
MAD reimburses a transportation provider for transportation
				  only when the transport is of a MAP eligible recipient and is subject to the
				  following conditions.
A.
Free
				alternatives:
Alternative transportation services that can be provided
				free of charge include volunteers, relatives or transportation services
				provided by nursing facilities (NF) or other residential centers.
B.
Least costly alternatives:
MAD covers the most appropriate and least costly transportation alternatives
				suitable for the MAP eligible recipient's medical or behavioral health
				condition. If a MAP eligible recipient can use a private vehicle or public
				transportation, those alternatives must be used before a MAP eligible recipient
				can use more expensive transportation alternatives.
C.
Non-emergency transportation
				service:
MAD covers non-emergency transportation services for a MAP
				eligible recipient who has no primary transportation and who is unable to
				access a less costly form of public transportation except as described under
				non-covered services. See 8.324.7.13 NMAC
.
D.
Long distance common
				carriers:
MAD covers long distance services furnished by a common
				carrier if a MAP eligible recipient must leave his or her home community to
				receive medical or behavioral health services. Authorization forms for direct
				payment to long distance bus common carriers by MAD are available through local
				county income support division (ISD) offices.
E.
Ground ambulance services:
MAD covers services provided by ground ambulances when:
(1) an emergency that requires ambulance
				service is certified by a physician or is documented in the provider's records
				as meeting emergency medical necessity criteria: terms are defined as follows:
(a) "emergency" is defined as a medical or
				behavioral health condition manifesting itself by acute symptoms of sufficient
				severity (including severe pain) such that a prudent layperson, who possesses
				an average knowledge of health and medicine could reasonably expect the absence
				of immediate medical attention to result in placing the health of the MAP
				eligible recipient (or with respect to a pregnant woman, the health of the
				woman or her unborn child) in serious jeopardy, serious impairment to body
				function or serious dysfunction of any bodily organ or part;
(b) "medical necessity" is established for
				ambulance services if the MAP eligible recipient's physical, or behavioral
				health condition is such that the use of any other method of transportation is
				contraindicated and would endanger the MAP eligible recipient's
				health.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 324 - ADJUNCT SERVICES › Part 7 - TRANSPORTATION SERVICES AND LODGING › Section 8.324.7.13 - NONCOVERED SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
Transportation services are subject to the same limitations
				  and coverage restrictions that exist for other MAD services. See 8.301.3 NMAC.
				  Payments for transportation for any non-covered service is subject to
				  retroactive recoupment.
A. MAD does
				not pay to transport a MAP eligible recipient to a medical or behavioral health
				service or provider that is not covered under the MAD program.
B. A provider will not be eligible to seek
				reimbursement from a MAP eligible recipient if the provider fails to notify the
				MAP eligible recipient or his or her authorized representative that the service
				is not covered by MAD. See 8.302.1 NMAC.
C. Transportation services will not be
				provided when other alternatives are available, such as mail delivery or free
				delivery. Retail pharmacies may mail, ship or deliver prescriptions to medicaid
				recipients consistent with applicable state and federal statutes and
				regulations.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 324 - ADJUNCT SERVICES › Part 7 - TRANSPORTATION SERVICES AND LODGING › Section 8.324.7.14 - OUT-OF-STATE TRANSPORTATION AND RELATED EXPENSES

Current through Register Vol. 35, No. 13, July 16, 2024
Out-of-state transportation and related expenses require
				  prior authorization by MAD or its designee. Out-of-state transportation is
				  authorized only if the out-of-state medical or behavioral health service is
				  approved by MAD or its designated contractor. Documentation must be available
				  to the reviewer to justify the out-of-state travel and verify that treatment is
				  not available in New Mexico.
A.
				Requests for out-of-state transportation must be coordinated through
				MAD.
B. Authorization for lodging
				and meal services by an out-of-state provider can be granted for up to 30 days
				by MAD. Re-evaluation authorizations are completed prior to expiration and
				every 30 days, thereafter.
C.
				Transportation to border cities, is defined as those cities within 100 miles of
				the New Mexico border (Mexico excluded), are treated as an in-state provider
				service. See 8.302.4 NMAC.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 324 - ADJUNCT SERVICES › Part 7 - TRANSPORTATION SERVICES AND LODGING › Section 8.324.7.15 - PRIOR AUTHORIZATION AND UTILIZATION REVIEW

Current through Register Vol. 35, No. 13, July 16, 2024
All MAD services are subject to utilization review (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. See 8.302.5 NMAC. The provider must contact HSD
				  or its authorized agents to request UR instructions. It is the provider's
				  responsibility to access these instructions or request hard copies to be
				  provided, to understand the information, to comply with the requirements, and
				  to obtain answers to questions not covered by these materials. When services
				  are billed to and paid by a MAD fee-for-service coordinated services
				  contractor, the provider must follow that contractor's instructions for
				  authorization of services.
A.
Prior authorization:
Certain procedures or services may require
				prior authorization from MAD or its designee. Services for which prior
				authorization is received remain subject to UR at any time during the payment
				process.
B.
Referrals for
				travel outside the home community:
(1)
				If a MAP eligible recipient must travel over 65 miles from his or her home
				community to receive medical or behavioral health care, the transportation
				provider must obtain and retain in its billing records written verification
				from the referring provider or the service provider containing the following:
(a) the medical, behavioral health or
				diagnostic service for which the MAP eligible recipient is being
				referred;
(b) the name of the out
				of community provider; and
(c)
				justification that the medical or behavioral health care is not available in
				the home community.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 324 - ADJUNCT SERVICES › Part 7 - TRANSPORTATION SERVICES AND LODGING › Section 8.324.7.16 - REIMBURSEMENT

Current through Register Vol. 35, No. 13, July 16, 2024
A. Transportation
				providers must submit claims for reimbursement on the CMS-1500 form or its
				successor. See 8.302.2 NMAC. Reimbursement to transportation, meal or lodging
				providers for covered services is made at the lesser of the following:
(1) the provider's billed charge:
(a) the billed charge must be the provider's
				usual and customary charge for services; for a provider with a tariff, the
				billed charge must be the lesser of the charges allowed by the provider's
				tariff or the provider's usual and customary charge.
(b) "usual and customary charge" refers to
				the amount an individual provider charges the general public in the majority of
				cases for a specific procedure or service; or
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 324 - ADJUNCT SERVICES › Part 10 - AMBULATORY SURGICAL CENTER SERVICES › Section 8.324.10.3 - 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 324 - ADJUNCT SERVICES › Part 10 - AMBULATORY SURGICAL CENTER SERVICES › Section 8.324.10.6 - 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 324 - ADJUNCT SERVICES › Part 10 - AMBULATORY SURGICAL CENTER SERVICES › Section 8.324.10.8 - 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 324 - ADJUNCT SERVICES › Part 10 - AMBULATORY SURGICAL CENTER SERVICES › Section 8.324.10.9 - AMBULATORY SURGICAL CENTER SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
New Mexico medicaid program (medicaid) pays for medically
				  necessary health services furnished to eligible recipients, including covered
				  services furnished in ambulatory surgical centers
				  42 CFR Section
				  440.20(a). This part
				  describes eligible providers, covered services, service limitations and general
				  reimbursement methodology.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 324 - ADJUNCT SERVICES › Part 10 - AMBULATORY SURGICAL CENTER SERVICES › Section 8.324.10.10 - ELIGIBLE PROVIDERS

Current through Register Vol. 35, No. 13, July 16, 2024
A. Upon
				approval of New Mexico medical assistance program provider participation
				application by the New Mexico medical assistance division (MAD), ambulatory
				surgical centers certified to participate in medicare under Title XVIII of the
				Social Security Act as free-standing ambulatory surgical centers are eligible
				to be reimbursed by medicaid for providing services as ambulatory surgical
				centers.
(1) The centers for medicare and
				medicaid (CMS) certify ambulatory surgical centers based on surveys and
				recommendations submitted by the licensing and certification bureau of the New
				Mexico department of health (DOH).
(2) Ambulatory surgical centers which are not
				free-standing but are part of an accredited and certified hospital are subject
				to 8.311.2 NMAC,
Hospital Services
.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 324 - ADJUNCT SERVICES › Part 10 - AMBULATORY SURGICAL CENTER SERVICES › Section 8.324.10.11 - PROVIDER RESPONSIBILITIES

Current through Register Vol. 35, No. 13, July 16, 2024
Providers who furnish services to medicaid recipients must
				  comply with all federal and state laws and regulations relevant to the
				  provision of medical services, including but not limited to, Title XIX of the
				  Social Security Act, the Medicare and Medicaid Anti-Fraud Act, and the state
				  Medicaid Fraud Act. Providers also agree to conform to MAD policies and
				  instructions as specified in this manual and its appendices, as updated. See
				  8.302.1 NMAC,
General Provider Policies
.
A. Recipient eligibility determination:
				Providers must verify that services they furnish are provided to eligible
				recipients.
(1) Providers may verify
				eligibility through several mechanisms, including the use of an automated voice
				response system, contacting the medicaid fiscal agent contractor eligibility
				help desk, contracting with a medicaid eligibility verification system (MEVS)
				vendor, or contracting with a medicaid magnetic swipe card vendor.
(2) Providers must verify that recipients are
				eligible for medicaid throughout periods of continued or extended services. By
				verifying client eligibility, a provider is informed of restrictions that may
				apply to a recipient's eligibility.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 324 - ADJUNCT SERVICES › Part 10 - AMBULATORY SURGICAL CENTER SERVICES › Section 8.324.10.12 - COVERED SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
A.
				Medicaid covers ambulatory surgical center facility services, as required by
				the condition of the recipient and if the following conditions are met:
(1) the surgical procedure and use of the
				facility are medically necessary and are covered by medicaid; and
(2) all medicaid requirements for the
				surgery, such as applicable consent forms or prior authorization requirements,
				are met by the physician.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 324 - ADJUNCT SERVICES › Part 10 - AMBULATORY SURGICAL CENTER SERVICES › Section 8.324.10.13 - NONCOVERED SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
Ambulatory surgical center services are subject to the
				  limitations and coverage restrictions which exist for other medicaid services.
				  If the surgery is non-covered, the anesthesia is non-covered. See 8.301.3 NMAC,
General Noncovered Services
.
A. Direct payment to physician. Ambulatory
				surgical centers are not reimbursed by medicaid for physician fees.
				Reimbursement for physician fees is made directly to the provider of the
				service.
B. Services furnished to
				dual eligible recipients. By federal regulation, the medicare program pays
				ambulatory surgical centers only for an approved list of specific surgical
				procedures. Medicare is the primary payment source for individuals who are
				eligible for both medicare and medicaid. For these recipients, medicaid will
				not pay an ambulatory surgical center for a surgical procedure denied by
				medicare.
Ambulatory surgical centers must refer these recipients to
				  facilities which medicare pays for the surgical procedure, such as an
				  outpatient hospital.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 324 - ADJUNCT SERVICES › Part 10 - AMBULATORY SURGICAL CENTER SERVICES › Section 8.324.10.14 - PRIOR AUTHORIZATION 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 authorization and claims
				  processing.
A. Prior authorization:
				Certain procedures or services can 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 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 authorization 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 324 - ADJUNCT SERVICES › Part 10 - AMBULATORY SURGICAL CENTER SERVICES › Section 8.324.10.15 - REIMBURSEMENT

Current through Register Vol. 35, No. 13, July 16, 2024
Ambulatory surgical centers must submit claims for
				  reimbursement on the CMS-1500 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.
A. Inclusion of all services in the facility
				fee: All services furnished by the facility are considered reimbursed in the
				facility fee and cannot be billed separately. The amount paid will be the
				lesser of the facility's usual and customary charge or the maximum allowed by
				medicaid.
B. Reimbursement
				methodology: The facility fee maximum is established at a level which considers
				the surgical procedure and the area in which the facility is located. Each
				surgical procedure is assigned to one of nine surgical groups, based on the
				complexity of the procedure. Each of these surgical groups has a separate
				reimbursement level. The level of reimbursement is determined by medicaid by
				utilizing the medicare carrier for procedures payable to ambulatory surgical
				centers by medicare regulations. The list of surgeries payable under medicare
				regulations also designates the assigned surgical group for payment purposes.
				The list is available from the medicare carrier.
(1) For those procedures for which medicare
				has not established a reimbursement level, MAD assigns the procedure to one of
				the nine surgical groups. The assignment is based upon the complexity of the
				procedure or its similarity to procedures within the surgical groups developed
				by medicare.
(2) Reimbursement is
				made at the level established by medicaid for that surgical group.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 325 - SPECIALTY SERVICES › Part 2 - DIALYSIS SERVICES › Section 8.325.2.3 - 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 325 - SPECIALTY SERVICES › Part 2 - DIALYSIS SERVICES › Section 8.325.2.6 - 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 325 - SPECIALTY SERVICES › Part 2 - DIALYSIS SERVICES › Section 8.325.2.8 - 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 325 - SPECIALTY SERVICES › Part 2 - DIALYSIS SERVICES › Section 8.325.2.9 - DIALYSIS SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
Dialysis services are covered as an optional medical service
				  for New Mexico medicaid program (medicaid) recipients
				  42 CFR Sections
				  440.10,
				  440.20;
				  440.50. This part describes
				  eligible dialysis providers, covered services, service limitations, and general
				  reimbursement methodology.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 325 - SPECIALTY SERVICES › Part 2 - DIALYSIS SERVICES › Section 8.325.2.10 - ELIGIBLE PROVIDERS

Current through Register Vol. 35, No. 13, July 16, 2024
A. Upon
				approval of New Mexico medical assistance program provider participation
				applications licensed practitioners or facilities that meet applicable
				requirements by the New Mexico medical assistance division (MAD), the following
				providers are eligible to be reimbursed for furnishing dialysis services to
				medicaid recipients:
(1) individuals licensed
				to practice medicine or osteopathy;
(2) facilities certified by the licensing and
				certification bureau of the department of health to furnish renal dialysis
				services; and
(3) hospitals
				eligible to participate in the New Mexico medicaid program. See 8.311.2 NMAC,
				Hospital Services.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 325 - SPECIALTY SERVICES › Part 2 - DIALYSIS SERVICES › Section 8.325.2.11 - PROVIDER RESPONSIBILITIES

Current through Register Vol. 35, No. 13, July 16, 2024
Providers who furnish services to medicaid recipients agree
				  to comply with all federal and state laws and regulations relevant to the
				  provision of medical services, including but not limited to, Title XIX of the
				  Social Security Act, the Medicare and Medicaid Anti Fraud Act, and the state
				  Medicaid Fraud Act. Providers also agree to conform to the MAD policies and
				  instructions as specified in this manual and its appendices, as updated.
A. Recipient eligibility verification:
				Providers must verify that services they furnish are provided to eligible
				recipients. Providers must verify that recipients are eligible and remain
				eligible for medicaid through periods of continued and extended services. By
				verifying eligibility, a provider is informed of restrictions that may apply to
				recipient's eligibility. Providers may verify eligibility through several
				mechanisms, including using an automated voice response system, contacting the
				medicaid fiscal agent contractor eligibility help desk, contracting with a
				medicaid eligibility verification system (MEVS) vendor, or contracting with a
				medicaid magnetic swipe card vendor.
B. Requirements for updating information:
				Providers must furnish in writing to MAD or the MAD claims processing
				contractor with complete information changes in their address, license,
				certification, board specialties, corporate name or corporate ownership, and a
				statement as to the continuing liability of the provider for any recoverable
				obligation to MAD which occurred or may have occurred prior to any sale,
				merger, consolidation, dissolution or other disposition of the health care
				provider group or individual.
C.
				Documentation requirements: Providers must maintain records to fully disclose
				the nature, quality, amount, and medical necessity of services furnished to
				recipients who are currently receiving or who have received medical services in
				the past.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 325 - SPECIALTY SERVICES › Part 2 - DIALYSIS SERVICES › Section 8.325.2.12 - COVERED SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
Medicaid covers renal dialysis services for the first three
				  months of dialysis pending the establishment of medicare eligibility. Medicare
				  becomes the primary reimbursement source for individuals who meet the medicare
				  eligibility criteria. Dialysis providers must assist medicaid recipients in
				  applying for and pursuing final medicare eligibility determinations. Medicaid
				  covers medically necessary dialysis supplies furnished to home-dialyzed
				  recipients. Medicaid covers medically necessary renal dialysis services
				  furnished by providers as required by the condition of the recipient. Medicaid
				  covers the following specific renal dialysis services:
A. Supplies, equipment and services included
				in the renal dialysis services composite rate: The facility reimbursement fee
				includes all renal-related facility and home dialysis services, including
				supplies and equipment. The following are some of the drugs, items and supplies
				included in the facility fee:
(1) hypertonic
				saline;
(2) dextrose
				(glucose);
(3) mannitol or similar
				product used for volume control;
(4) heparin;
(5) protamine;
(6) antiarrhythmics;
(7) antihistamines;
(8) antihypertensives;
(9) pressor drugs;
(10) antibiotics (when used at home by a
				patient to treat an infection of the catheter site or peritonitis associated
				with peritoneal dialysis);
(11)
				oxygen;
(12) filters;
(13) bicarbonate dialysate;
(14) cardiac monitoring;
(15) catheters and catheter
				changes;
(16) suture removal kits
				and suture removal;
(17) dressing
				supplies;
(18) crash cart usage for
				cardiac arrest;
(19) declotting of
				shunt performed by facility staff in the dialysis unit;
(20) staff time to administer
				blood;
(21) staff time to
				administer separately billable parenteral items; and
(22) staff time used to collect all specimens
				for laboratory tests.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 325 - SPECIALTY SERVICES › Part 2 - DIALYSIS SERVICES › Section 8.325.2.13 - SERVICE LIMITATIONS

Current through Register Vol. 35, No. 13, July 16, 2024
Tests that are listed as separately billable (not included in
				  the composite rate) and are performed at a frequency greater than specified in
				  the composite rate require medical justification and are covered when furnished
				  at specified frequencies.
A. Tests for
				hemodialysis, peritoneal dialysis and CCPD: (Not included in the composite
				rate). These services may be billed separately at the specified frequencies.
(1) Monthly:
(a) alkaline phosphatase;
(b) alkaline phosphatase;
(c) blood urea nitrogen (BUN);
(d) serum bicarbonate
				(CO2);
(e)
				dialysis protein;
(f)
				hematocrit;
(g)
				hemoglobin;
(h) lactic
				dehydrogenase (LDH);
(i)
				magnesium;
(j) serum
				albumin;
(k) serum
				creatinine;
(l) serum
				phosporus;
(m) serum
				potassium;
(n) SGOT;
(o) sodium;
(p) total protein;
(q) serum calcium;
(r) hepatitis test.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 325 - SPECIALTY SERVICES › Part 2 - DIALYSIS SERVICES › Section 8.325.2.14 - NONCOVERED SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
Dialysis services are subject to the limitations and coverage
				  restrictions of other medicaid services. See 8.301.3 NMAC,
General
				  Noncovered Services
.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 325 - SPECIALTY SERVICES › Part 2 - DIALYSIS SERVICES › Section 8.325.2.15 - PRIOR AUTHORIZATION 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 authorization and claims
				  processing.
A. Prior authorization:
				Certain procedures or services can 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 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 authorization 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 325 - SPECIALTY SERVICES › Part 2 - DIALYSIS SERVICES › Section 8.325.2.16 - REIMBURSEMENT

Current through Register Vol. 35, No. 13, July 16, 2024
Dialysis facilities must submit claims for reimbursement on
				  the UB-92 claim form or its successor. Physicians must submit for reimbursement
				  on the CMS-1500 claim form or its successor. See 8.302.2 NMAC,
Billing
				  for Medicaid Services
.
The facility's composite rate reimbursement is a
				  comprehensive payment for all in facility and home dialysis services. Providers
				  cannot bill separately for services inclusive of the composite rate, as defined
				  by medicare, even though payment is made at the medicaid fee schedule.
				  Physicians services are not included in the facilities composite rate.
				  Physicians may bill for their professional services according to the policies
				  and procedures outlined in the 8.310.2 NMAC,
Medical Services
				  Providers
. Laboratory procedures and radiology procedures that are not
				  part of the facilities composite rate, as defined by medicare, may be billed
				  separately.
A. Certified
				hospital-based dialysis facilities are reimbursed at a rate determined by the
				medicaid outpatient hospital reimbursement methodology.
B. Hospital providers are reimbursed for
				inpatient renal dialysis at a rate determined by the medicaid inpatient
				hospital reimbursement methodology.
C. Renal dialysis facilities acting as
				suppliers to a home-dialyzed recipient can bill medicaid for the necessary
				supplies furnished to the recipient only if the facility is not billing a
				facility fee. Facilities cannot bill for both a facility fee and
				supplies.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 325 - SPECIALTY SERVICES › Part 4 - HOSPICE CARE SERVICES › Section 8.325.4.3 - 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 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 325 - SPECIALTY SERVICES › Part 4 - HOSPICE CARE SERVICES › Section 8.325.4.6 - 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 325 - SPECIALTY SERVICES › Part 4 - HOSPICE CARE SERVICES › Section 8.325.4.8 - 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 325 - SPECIALTY SERVICES › Part 4 - HOSPICE CARE SERVICES › Section 8.325.4.9 - HOSPICE CARE SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
Hospice services are covered as an optional medical service
				  for New Mexico medicaid program (medicaid) recipients.
Hospice services provide palliative and supportive services
				  to meet the physical, psychological, social, and spiritual needs of terminally
				  ill medicaid recipients and their families. This part describes eligible
				  providers covered services, service limitations, and general reimbursement
				  methodology.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 325 - SPECIALTY SERVICES › Part 4 - HOSPICE CARE SERVICES › Section 8.325.4.10 - ELIGIBLE PROVIDERS

Current through Register Vol. 35, No. 13, July 16, 2024
A. Upon
				approval of New Mexico medical assistance program provider participation by the
				New Mexico medical assistance division (MAD), hospice agencies meeting the
				following conditions are eligible to be reimbursed for providing hospice care
				services:
(1) meet the conditions for
				participation: see 42 CFR 418.50 et. seq.;
(2) licensed and certified by the licensing
				and certification bureau of the New Mexico department of health (DOH);
				and
(3) are a public or private
				non-profit or for profit agency or a subdivision of either, primarily engaged
				in providing care to terminally ill individuals.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 325 - SPECIALTY SERVICES › Part 4 - HOSPICE CARE SERVICES › Section 8.325.4.11 - PROVIDER RESPONSIBILITIES

Current through Register Vol. 35, No. 13, July 16, 2024
Providers who furnish services to medicaid recipients must
				  comply with all federal and state laws and regulations relevant to the
				  provision of medical services, including but not limited to Title XIX of the
				  Social Security Act, the Medicare and Medicaid Anti-Fraud Act, and the state
				  Medicaid Fraud Act. Providers also agree to conform to MAD policies and
				  instructions as specified in this manual and it appendices, as updated. 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 to fully disclose the nature, quality, amount, and
				  medical necessity of the services furnished to recipients who are currently
				  receiving or who have received medical services in the past
				  42 CFR
				  431.107(B). Documentation
				  supporting medical necessity must be legible and available to medicaid upon
				  request. See 8.302.1 NMAC,
General Provider
				  Policies
.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 325 - SPECIALTY SERVICES › Part 4 - HOSPICE CARE SERVICES › Section 8.325.4.12 - ELIGIBLE RECIPIENTS

Current through Register Vol. 35, No. 13, July 16, 2024
To be eligible for hospice care, a physician must provide a
				  written certification that the recipient has a terminal illness. Recipients
				  must elect to receive hospice care for the duration of the election
				  period.
A. Certification of terminal
				illness: The hospice must obtain a written certification statement signed by
				the hospice medical director, physician member of the hospice interdisciplinary
				team or recipient's attending physician that the recipient is terminally ill.
				The physician must sign the written certification within seven calendar days of
				the date services are initiated. Certification statements must include
				information that is based on the recipient's medical prognosis, and the life
				expectancy is six months or less if the terminal illness runs its typical
				course.
(1) If a recipient receives hospice
				benefits beyond 210 days, the hospice must obtain a written recertification
				statement from the hospice medical director or the physician member of the
				hospice interdisciplinary group before the 210-day period expires.
(2) Hospice benefits furnished beyond the
				210-day period may be subject to medical review.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 325 - SPECIALTY SERVICES › Part 4 - HOSPICE CARE SERVICES › Section 8.325.4.13 - COVERED SERVICES AND SERVICE LIMITATIONS

Current through Register Vol. 35, No. 13, July 16, 2024
For recipients electing hospice care, medicaid covers hospice
				  core services furnished to eligible recipients that are reasonable and
				  necessary for the palliation or symptom management of a recipient's terminal
				  illness and related conditions. Hospice core services include the medications,
				  durable medical equipment and medical supplies needed to deliver palliative
				  care. Hospice providers are reimbursed for the delivery of core services based
				  on daily rate.
A. The hospice services
				necessary for a specific recipient must be documented in an individualized
				treatment plan. The plan must be developed by attending physicians, medical
				directors and interdisciplinary groups and must meet certain requirements: See
				42 CFR 418.50 et. seq.
(1) Hospices must
				designate a registered nurse to coordinate the implementation of each
				recipient's plan of care.
(2) The
				interdisciplinary group, including nursing services, medical social services,
				physician services and counseling services practitioners are responsible for
				the following:
(a) developing the plan of
				care;
(b) providing or supervising
				hospice care and services;
(c)
				reviewing and updating the plan of care;
(d) establishing policies for daily provision
				of hospice care and services; and
(e) coordinating with other medicaid support
				service providers such that the plan of care is not duplicative of hospice
				services.
(3) All
				hospice services must be available 24 hours per day to the extent necessary to
				meet the needs of the terminally ill recipients.