reglab/statecodes huggingface dataset:
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 310 - HEALTH CARE PROFESSIONAL SERVICES › Part 9 - RURAL HEALTH CLINIC SERVICES › Section 8.310.9.13 - NON-CORE MEDICAL SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
Core medical services, as defined in the Rural Health Clinic
				  Act, performed at rural health clinics are included in the encounter rate for
				  purposes of medicaid reimbursement. The following non-core services may be
				  provided in rural clinics, however, reimbursement for these services is not
				  included in the encounter rate:
A.
				optometric services, including vision examinations and eyeglasses
				dispensing;
B. hearing aid
				dispensing and related evaluations;
C. psychological services;
D. rural health drug services; and
(1) pharmacy services are covered by medicaid
				if the rural health clinic obtains a separate pharmacy provider number; a
				separate New Mexico medical assistance program provider participation
				application must be submitted for pharmacy services and be approved by
				MAD;.
(2) pharmacy dispensing
				services must be billed with the separate pharmacy provider number;.
(3) the rural health clinic pharmacy must be
				licensed by the state pharmacy board; see 8.324.4 NMAC,
Pharmacy
				Services
.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 310 - HEALTH CARE PROFESSIONAL SERVICES › Part 9 - RURAL HEALTH CLINIC SERVICES › Section 8.310.9.14 - NONCOVERED SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
Rural health clinic services are subject to the same
				  limitations and coverage restrictions which exist for other medicaid services.
				  See 8.301.3 NMAC,
General Noncovered
				  Services
.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 310 - HEALTH CARE PROFESSIONAL SERVICES › Part 9 - RURAL HEALTH CLINIC SERVICES › Section 8.310.9.15 - 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 may 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 may 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 re-review and a
				reconsideration. See Section MAD-953,
Reconsideration of Utilization
				Review Decisions
.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 310 - HEALTH CARE PROFESSIONAL SERVICES › Part 9 - RURAL HEALTH CLINIC SERVICES › Section 8.310.9.16 - REIMBURSEMENT

Current through Register Vol. 35, No. 13, July 16, 2024
Rural health clinics must submit claims for reimbursement on
				  the UB-92 claim form or its successor. See 8.302.2 NMAC,
Billing for
				  Medicaid Services
. Once enrolled, providers receive instructions on
				  documentation, billing, and claims processing.
A.
Reimbursement for non-hospital based
				rural health clinics:
Interim reimbursement is made at an encounter rate
				established for the clinic by the medicare intermediary.
(1) An "encounter" means a face-to-face
				meeting between a recipient and any health professional whose services are
				reimbursed as a covered rural health clinic service.
(2) A final cost settlement based on the
				audit data is made in accordance with applicable medicare regulations following
				the medicare cost settlement.
(3)
				Multiple encounters with the same or different health professional(s) that take
				place on the same date at a single location are considered a single encounter.
(a) Exceptions exist for cases in which the
				recipient suffers illness or injury requiring additional diagnosis or treatment
				on the same day, after the first encounter.
(b) All medical, surgical, diagnostic
				imaging, supplies, and clinical laboratory services furnished during the
				encounter are considered reimbursed within the encounter rate.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 310 - HEALTH CARE PROFESSIONAL SERVICES › Part 10 - HEALTH HOME SERVICES › Section 8.310.10.3 - 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 Sections
				  27-2-12
				  et seq. NMSA 1978.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 310 - HEALTH CARE PROFESSIONAL SERVICES › Part 10 - HEALTH HOME SERVICES › Section 8.310.10.6 - OBJECTIVE

Current through Register Vol. 35, No. 13, July 16, 2024
The objective of this rule is to provide instructions for the
				  service portion of the New Mexico medical assistance programs (MAP).
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 310 - HEALTH CARE PROFESSIONAL SERVICES › Part 10 - HEALTH HOME SERVICES › Section 8.310.10.9 - HEALTH HOMES

Current through Register Vol. 35, No. 13, July 16, 2024
CareLink NM is a set of services authorized by Section 2703
				  of the Affordable Care Act (ACA). CareLink NM health home (CareLink NM)
				  services are delivered through a designated provider agency. In addition to
				  being enrolled as a provider, a provider agency must complete a CareLink NM
				  application and successfully complete a readiness assessment by HSD prior to
				  becoming a designated health home. CareLink NM services enhance the integration
				  and the coordination of primary, acute, behavioral health, and long-term
				  services and supports. The CareLink NM provider agency assists an eligible
				  recipient by engaging him or her in a comprehensive needs assessment which is
				  then utilized to develop his or her integrated service plan and individual
				  treatment plan, increasing his or her access to health education and promotion
				  activities, monitoring the eligible recipient's treatment outcomes and
				  utilization of resources, coordinating appointments with the eligible
				  recipient's primary care and specialty practitioners, sharing information among
				  his or her physical and behavioral practitioners to reduce the duplication of
				  services, actively managing the eligible recipient's transitions between
				  services, and participating as appropriate in the development of the eligible
				  recipient's hospital discharge.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 310 - HEALTH CARE PROFESSIONAL SERVICES › Part 10 - HEALTH HOME SERVICES › Section 8.310.10.11 - PROVIDER RESPONSIBILITIES

Current through Register Vol. 35, No. 13, July 16, 2024
A. A
				provider agency who furnishes MAD services to an eligible recipient must comply
				with all federal and state laws, rules, regulations, and executive orders
				relevant to the provision of services as specified in the MAD PPA. A provider
				agency also must comply with all appropriate New Mexico administrative code
				(NMAC) rules, billing instructions, supplements, and policy, as updated. A
				provider agency is also responsible for following coding manual guidelines and
				centers for medicare and medicaid services (CMS) national correct coding
				initiatives (NCCI), including not improperly unbundling or upcoding
				services.
B. A provider agency must
				verify that a recipient is eligible for a specific health care program
				administered by HSD and its authorized agents, and must verify the recipient's
				enrollment status at the time services are furnished. A provider agency must
				determine if an eligible recipient has other health insurance and notify HSD. A
				provider agency must maintain records that are sufficient to fully disclose the
				extent and nature of the services provided to an eligible recipient.
C. When services are billed to and paid by a
				MAD fee-for-service (FFS) coordinated services contractor authorized by HSD,
				under an administrative services contract, the provider agency must also enroll
				as a provider with the coordinated services contractor and follow that
				contractor's instructions for billing and for authorization of services; see
				8.302.1 NMAC.
D.The provider agency
				must:
(1) demonstrate the ability to meet all
				data and quality reporting requirements as detailed in the CareLink NM policy
				manual;
(2) be approved through a
				HSD application and readiness process as described in the CareLink NM policy
				manual;
(3) have the ability to
				provide primary care services for all ages of eligible recipients, or have a
				memorandum of agreement with at least one primary care practice in the area
				that serves eligible recipients under 21 years of age, and one that serves
				eligible recipients 21 years of age and older;
(4) have established eligible recipient
				referral protocols with the area hospitals and residential treatment
				facilities;
(5) maintain the
				following suggested range of care coordinator staff ratios for CareLink NM
				eligible recipients as described in the CareLink NM policy manual:
(a) 1:51-100 for care coordination level
				6;
(b) 1:30-50 for care
				coordination level 7;
(c) 1:50 for
				care coordination level 8; and
(d)
				1:10 for care coordination level 9.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 310 - HEALTH CARE PROFESSIONAL SERVICES › Part 10 - HEALTH HOME SERVICES › Section 8.310.10.12 - IDENTIFIED POPULATION

Current through Register Vol. 35, No. 13, July 16, 2024
An eligible recipient:
A. is 21 years of age and older who meets the
				HSD criteria for serious mental illness (SMI); or
B. is under 21 years of age who meets the HSD
				criteria for serious emotional disturbance (SED).
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 310 - HEALTH CARE PROFESSIONAL SERVICES › Part 10 - HEALTH HOME SERVICES › Section 8.310.10.13 - COVERED SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
Health home services through CareLink NM are coordinated
				  with the eligible recipient and his or her family and a CareLink NM provider
				  agency as appropriate. CareLink NM services identify available community-based
				  resources and actively manage appropriate referrals and access to care,
				  engagement with other community and social supports, and follow-up post
				  engagement. Common linkages include continuation of the eligible recipient's
				  MAP category of eligibility, and his or her other disability benefits, housing
				  assistance, legal services, educational and employment supports, and other
				  personal needs consistent with his or her recovery goals and CareLink NM care
				  plan. CareLink NM staff make and follow-up on referrals to community services,
				  link an eligible recipient with natural supports, and assure that these
				  connections are solid and effective. Services are linked as appropriate and
				  feasible by health information technology. CareLink NM services are comprised
				  of six unique categories (and further defined in the CareLink NM policy
				  manual):
A. comprehensive care
				management;
B. care coordination
				;
C. health promotion;
D. comprehensive transitional care;
E. individual and family support services;
				and
F. referrals for the eligible
				recipient to community and social support services
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 310 - HEALTH CARE PROFESSIONAL SERVICES › Part 10 - HEALTH HOME SERVICES › Section 8.310.10.14 - GENERAL NON-COVERED SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
Non-covered CareLink NM services are subject to the
				  limitations and coverage restrictions that exist for other MAD services. See
				  8.310.2 and 8.321.2 NMAC for general non-covered services. Specific to CareLink
				  NM services, the following apply:
A.
				CareLink NM services rendered during an eligible recipient's stay in an acute
				care or freestanding psychiatric hospital and a residential treatment facility
				(not to include foster care and treatment foster care placements), except when
				part of the eligible recipient's transition plan, are not covered
				services.
B. Services which
				duplicate other MAD services, including care coordination activities that the
				MCO has not delegated to the provider agency, are not covered
				services.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 310 - HEALTH CARE PROFESSIONAL SERVICES › Part 10 - HEALTH HOME SERVICES › Section 8.310.10.15 - PRIOR AUTHORIZATION (PA) AND UTILIZATION REVIEW (UR)

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, before payment is made,
				  or after payment is made. The provider agency must contact MAD or its designees
				  to request UR instructions. It is the provider agency's responsibility to
				  access these instructions or ask for hard copies to be provided, to understand
				  the information provided, 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 coordinated services contractor authorized by HSD, the
				  provider agency and practitioner must follow that contractor's instructions for
				  authorization of services. A provider agency and practitioner rendering
				  services to a member must comply with that MCO's prior authorization
				  requirements.
A.
Prior
				authorization:
CareLink NM services do not require prior authorization,
				but are provided as approved by the CareLink provider agency. However, other
				procedures or services may require a prior authorization from MAD or its
				designee. Services for which a prior authorization is required remain subject
				to UR at any point in the payment process, including after payment has been
				made. It is the provider agency's responsibility to contact MAD or its designee
				and review documents and instructions available from MAD or its designee to
				determine when a prior authorization is necessary.
B.
Timing of UR:
A UR may be
				performed at any time during the service, payment, or post payment processes.
				In signing the MAD PPA, a provider agency agrees to cooperate fully with MAD or
				its designee in its performance of any review and agrees to comply with all
				review requirements. The following are examples of the reviews that may be
				performed:
(1) prior authorization review
				(review occurs before the service is furnished);
(2) concurrent review (review occurs while
				service is being furnished);
(3)
				pre-payment review (claims review occurring after service is furnished but
				before payment);
(4) retrospective
				review (review occurs after payment is made); and
(5) one or more reviews may be used by MAD to
				assess the medical necessity and program compliance of any service.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 310 - HEALTH CARE PROFESSIONAL SERVICES › Part 12 - INDIAN HEALTH SERVICE AND TRIBAL 638 FACILITIES › Section 8.310.12.3 - STATUTORY AUTHORITY

Current through Register Vol. 35, No. 13, July 16, 2024
The New Mexico medicaid program and other health care
				  programs are administered pursuant to regulations promulgated by the federal
				  department of health and human services under Title XIX of the Social Security
				  Act as amended or by state statute. See Section 27-2-12 et seq. NMSA 1978.
				  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 310 - HEALTH CARE PROFESSIONAL SERVICES › Part 12 - INDIAN HEALTH SERVICE AND TRIBAL 638 FACILITIES › Section 8.310.12.5 - EFFECTIVE DATE

Current through Register Vol. 35, No. 13, July 16, 2024
November 1, 2014, unless a later date is cited at the end of
				  a section.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 310 - HEALTH CARE PROFESSIONAL SERVICES › Part 12 - INDIAN HEALTH SERVICE AND TRIBAL 638 FACILITIES › Section 8.310.12.6 - OBJECTIVE

Current through Register Vol. 35, No. 13, July 16, 2024
The objective of these rules is to provide instruction for
				  the service portion of the New Mexico medical assistance programs
				  (MAP).
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 310 - HEALTH CARE PROFESSIONAL SERVICES › Part 12 - INDIAN HEALTH SERVICE AND TRIBAL 638 FACILITIES › Section 8.310.12.8 - 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 310 - HEALTH CARE PROFESSIONAL SERVICES › Part 12 - INDIAN HEALTH SERVICE AND TRIBAL 638 FACILITIES › Section 8.310.12.9 - INDIAN HEALTH SERVICE AND TRIBAL 638 FACILITIES

Current through Register Vol. 35, No. 13, July 16, 2024
HSD, through the medical assistance division (MAD), pays for
				  medically necessary health services furnished to an eligible recipient,
				  including American Indian and Alaska native (AI/AN) eligible recipients. The
				  Indian health service (IHS) is a federal agency within the United States
				  department of health and human services (DHHS) that is responsible for
				  providing health services to AI/ANs based on the unique
				  government-to-government relationship between federally recognized tribes and
				  nations and the federal government. The IHS health care delivery system
				  consists of health facilities owned and operated by IHS, facilities owned by
				  IHS and operated by tribes or tribal organizations under Title I or Title III
				  of the Indian Self-Determination and Education Assistance Act ( Public Law
				  93-638, as amended) agreements, and facilities owned and operated by tribes or
				  tribal organizations under such agreements, hereafter referred to as "IHS and
				  tribal 638 facilities". Pursuant to Section 1911 of the Social Security Act;
				  see 42 U.S.C. 1369 j and the 1996 memorandum of agreement between IHS and the
				  centers for medicare and medicaid services (CMS), IHS and tribal 638 facilities
				  are eligible to be reimbursed by MAD for furnishing covered healthcare services
				  to a MAP eligible AI/AN recipient (eligible recipient). Specific to this rule,
				  an eligible recipient includes a member enrolled in a HSD contracted managed
				  care organization (MCO).
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 310 - HEALTH CARE PROFESSIONAL SERVICES › Part 12 - INDIAN HEALTH SERVICE AND TRIBAL 638 FACILITIES › Section 8.310.12.10 - ELIGIBLE PROVIDERS

Current through Register Vol. 35, No. 13, July 16, 2024
A. Health
				care to an eligible recipient is furnished by a variety of providers and
				provider groups. Reimbursement and billing for these services are administered
				by MAD. Upon approval of a New Mexico provider participation agreement (PPA) by
				MAD or its designee, licensed practitioners, facilities and other providers of
				services that meet applicable requirements are eligible to be reimbursed for
				furnishing covered services to an eligible recipient. Providers must be
				enrolled before submitting a claim for payment to the MAD claims processing
				contractor. MAD makes available on the HSD website, on other program specific
				websites, or in hard copy format, information necessary to participate in
				health care programs administered by HSD or its authorized agents, including
				program rules, billing instructions, utilization review instructions, and other
				pertinent material. When enrolled, a provider receives instruction on how to
				access these documents. It is the provider's responsibility to access these
				instructions, to understand the information provided therein and comply with
				the requirements. Providers must contact MAD for answers to billing questions
				or any of these materials. To be eligible for reimbursement, a provider must
				adhere to provisions of the MAD PPA and applicable statutes, regulations, rules
				and executive orders. MAD, or its selected claims processing contractor, issues
				payment to a provider using electronic funds transfer (EFT) only. Upon approval
				of the provider's PPA by MAD, the following practitioners and facilities may be
				enrolled as MAD providers:
(1) IHS
				facilities;
(2)Public Law 93-638
				tribal facilities;
(3) urban Indian
				facilities (follows the rules for a federally qualified health
				center);
(4) IHS or tribal 638
				facility pharmacies which follow 8.324.4 NMAC; and
(5) off site locations on federal land and
				facilities approved by MAD.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 310 - HEALTH CARE PROFESSIONAL SERVICES › Part 12 - INDIAN HEALTH SERVICE AND TRIBAL 638 FACILITIES › Section 8.310.12.11 - PROVIDER RESPONSIBILITIES AND REQUIREMENTS

Current through Register Vol. 35, No. 13, July 16, 2024
A. A provider who furnishes services to an
				eligible recipient must comply with all applicable laws, regulations, rules,
				standards, and the provisions of the MAD PPA. A provider must adhere to MAD
				program rules as specified in the New Mexico administrative code (NMAC) and
				program policies that include, but are not limited to, supplements, billing
				instructions, and utilization review 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. A provider must
				determine if an eligible recipient has other applicable health insurance. A
				provider must maintain records that are sufficient to fully disclose the extent
				and nature of the services provided to an eligible recipient.
C. Services furnished must be within the
				scope of practice defined by the provider's licensing board, scope of practice
				act or regulatory authority, or as customarily provided under IHS or public
				health service administrative direction including the level of supervision
				required for services.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 310 - HEALTH CARE PROFESSIONAL SERVICES › Part 12 - INDIAN HEALTH SERVICE AND TRIBAL 638 FACILITIES › Section 8.310.12.13 - PRIOR AUTHORIZATION AND UTILIZATION REVIEW

Current through Register Vol. 35, No. 13, July 16, 2024
IHS and tribal 638 facilities need not obtain prior
				  authorization for services, but must continue to follow standards of care
				  within its scope of practice and retain documentation in the eligible
				  recipient's physical and behavioral health record. MAD services are subject to
				  utilization review for medical necessity and program compliance. Reviews may be
				  performed before or after services are furnished.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 310 - HEALTH CARE PROFESSIONAL SERVICES › Part 12 - INDIAN HEALTH SERVICE AND TRIBAL 638 FACILITIES › Section 8.310.12.14 - NON-COVERED SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
For a detailed description of general non-covered MAD
				  services, see 8.310.2 NMAC and 8.321.2 NMAC. Other MAD service rules may have
				  additional non-covered MAD service restrictions.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 310 - HEALTH CARE PROFESSIONAL SERVICES › Part 12 - INDIAN HEALTH SERVICE AND TRIBAL 638 FACILITIES › Section 8.310.12.15 - REIMBURSEMENT

Current through Register Vol. 35, No. 13, July 16, 2024
OMB rates are published annually in the federal register and
				  are applicable to an IHS and a tribal 638 facility. These rates are applied
				  retroactively to their effective date.
A. IHS OMB outpatient and inpatient
				reimbursement rates include facility fees and professional fees except as
				described in this rule.
(1) Outpatient
				encounters and visits: MAD reimburses outpatient encounters and visits at the
				OMB outpatient encounter rate. Reimbursement at OMB rates is retroactive to the
				dates of service for which the OMB rates are applicable.
(2) Inpatient hospital service: MAD
				reimburses covered inpatient hospital stays at the federally published OMB
				hospital inpatient per diem rate. The inpatient OMB rate applies when an
				eligible recipient has been under outpatient care observation or is receiving
				extended outpatient medical services, and the time period has been for 24 hours
				or more whether the eligible recipient has been formally admitted or not. Risk
				factors such as distance of the facility from the eligible recipient's
				residence for potential emergency follow up care, as well as lack of
				availability of step-down care providers (home health services, nursing
				facilities, and acute long term care hospital facilities) may be considered in
				making discharge decisions regarding the eligible recipient. Alternatively, the
				facility may elect to bill a daily outpatient OMB rate for an eligible
				recipient under observation. Reimbursement at OMB rates is retroactive to the
				date of service for which the federal OMB rates are applicable.
(3) Reimbursement following medicare payment
				is made at the full copayment, deductible and co-insurance amounts determined
				by medicare. Reimbursement following payment by other insurance is made at the
				OMB rate, is applicable, less the payment received from the other
				insurer.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 311 - HOSPITAL SERVICES › Part 2 - HOSPITAL SERVICES › Section 8.311.2.3 - STATUTORY AUTHORITY

Current through Register Vol. 35, No. 13, July 16, 2024
The New Mexico medicaid program and other health care
				  programs are administered pursuant to regulations promulgated by the federal
				  department of health and human services under the Social Security Act as
				  amended, or by state statute. See Section 27-2-12 et seq. NMSA 1978. Section
				  9-8-1 et seq. NMSA 1978 establishes the health care authority (HCA) as a
				  single, unified department to administer laws and exercise functions relating
				  to health care facility licensure and health care purchasing and
				  regulation.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 311 - HOSPITAL SERVICES › Part 2 - HOSPITAL SERVICES › Section 8.311.2.8 - 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 311 - HOSPITAL SERVICES › Part 2 - HOSPITAL SERVICES › Section 8.311.2.9 - HOSPITAL SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
The New Mexico medical assistance division (MAD) pays for
				  medically necessary health services furnished to eligible recipients. To help
				  New Mexico eligible recipients receive necessary services, MAD pays for
				  inpatient, outpatient, and emergency services furnished in general hospital
				  settings.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 311 - HOSPITAL SERVICES › Part 2 - HOSPITAL SERVICES › Section 8.311.2.10 - ELIGIBLE PROVIDERS

Current through Register Vol. 35, No. 13, July 16, 2024
Health care to eligible recipients is furnished by a variety
				  of providers and provider groups. The reimbursement and billing for these
				  services is administered by MAD. Upon approval of a New Mexico MAD provider
				  participation agreement by MAD or its designee, licensed practitioners,
				  facilities and other providers of services that meet applicable requirements
				  are eligible to be reimbursed for furnishing covered services to eligible
				  recipients. A provider must be enrolled before submitting a claim for payment
				  to the MAD claims processing contractors. MAD makes available on the HCA/MAD
				  website, on other program-specific websites, or in hard copy format,
				  information necessary to participate in health care programs administered by
				  HCA or its authorized agents, including program rules, billing instructions,
				  utilization review instructions, and other pertinent materials. When enrolled,
				  a provider receives instruction on how to access these documents. It is the
				  provider's responsibility to access these instructions, to understand the
				  information provided and to comply with the requirements. The provider must
				  contact HCA or its authorized agents to obtain answers to questions related to
				  the material. To be eligible for reimbursement, a provider must adhere to the
				  provisions of the MAD provider participation agreement and all applicable
				  statutes, regulations, and executive orders. MAD or its selected claims
				  processing contractor issues payments to a provider using electronic funds
				  transfer (EFT) only. Eligible providers include:
A. a general acute care hospital,
				rehabilitation, extended care or other specialty hospital:
(1) licensed by the New Mexico department of
				health (DOH), and
(2) participating
				in the Title XVIII (medicare) program or accredited by the joint commission
				(previously known as JCAHO accreditation);
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 311 - HOSPITAL SERVICES › Part 2 - HOSPITAL SERVICES › Section 8.311.2.11 - PROVIDER RESPONSIBILITIES

Current through Register Vol. 35, No. 13, July 16, 2024
A. A
				provider who furnishes services to an eligible recipient must comply with all
				federal and state laws, regulations and executive orders relevant to the
				provision of services as specified in the MAD provider participation agreement.
				A provider also must conform to MAD program rules and instructions as specified
				in the provider rules manual and its appendices, as well as current program
				directions and billing instructions, as updated. A provider is also responsible
				for following coding manual guidelines and CMS correct coding initiatives,
				including not improperly unbundling or upcoding services.
B. A provider must verify that an individual
				is eligible for a specific health care program administered by the HCA and its
				authorized agents and must verify the eligible recipient's enrollment status at
				the time services are furnished. A provider must determine if an 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
				an eligible recipient. See 8.302.1 NMAC,
General Provider
				Policies
.
C. A provider
				agrees to be paid by the MAD managed care organizations (MCOs) at any amount
				mutually-agreed between the provider and MCOs when the provider enters into
				contracts with MCOs contracting with HCA for the provision of managed care
				services to the MAD population.
(1) If the
				provider and the MCOs are unable to agree to terms or fail to execute an
				agreement for any reason, the MCOs shall be obligated to pay, and the provider
				shall accept, one hundred percent of the "applicable reimbursement rate" based
				on the provider type for services rendered under both emergency and
				nonemergency situations.
(2) The
				"applicable reimbursement rate" is defined as the rate paid by HCA to the
				provider participating in medicaid or other medical assistance programs
				administered by HCA and excludes disproportionate share hospital and medical
				education payments.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 311 - HOSPITAL SERVICES › Part 2 - HOSPITAL SERVICES › Section 8.311.2.12 - COVERED SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
MAD covers inpatient and outpatient hospital, and emergency
				  services which are medically necessary for the diagnosis, the treatment of an
				  illness or injury or as required by the condition of the eligible recipient.
				  MAD covers items or services ordinarily furnished by a hospital for the care
				  and treatment of an eligible recipient. These items or services must be
				  furnished under the direction of an enrolled MAD physician, podiatrist, or
				  dentist with staff privileges in a hospital which is an enrolled MAD provider.
				  Services must be furnished within the scope and practice of the profession as
				  defined by state laws and in accordance with applicable federal and state and
				  local laws and regulations.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 311 - HOSPITAL SERVICES › Part 2 - HOSPITAL SERVICES › Section 8.311.2.13 - PRIOR AUTHORIZATION AND UTILIZATION REVIEW

Current through Register Vol. 35, No. 13, July 16, 2024
All MAD services are subject to utilization review for
				  medical necessity and program compliance. Reviews may 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
. It is the provider's responsibility to access
				  these instructions or ask for paper copies to be provided, to understand the
				  information provided, 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 coordinated services contractor authorized by HCA, 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. A procedure
				that requires prior authorization is primarily one for which the medical
				necessity may be uncertain, which may be for cosmetic purposes, or which may be
				of questionable effectiveness or long-term benefit.
(1) All transfers from one acute care DRG
				reimbursed hospital to another DRG reimbursed hospital.
(2) All inpatient stays for a PPS-exempt
				psychiatric unit of a general acute care hospital requires admission and
				continued stay reviews.
(3) All
				inpatient stays in a rehabilitation hospital, a PPS-exempt rehabilitation unit
				in a general acute care hospital, and an extended care or other specialty
				hospital requires admission and continued stay reviews.
(4) Outpatient physical, occupational, and
				speech therapies services require prior authorization.
(5) Services for which prior authorization
				was obtained remain subject to utilization review at any point in the payment
				process.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 311 - HOSPITAL SERVICES › Part 2 - HOSPITAL SERVICES › Section 8.311.2.14 - INPATIENT SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
MAD coverage of some inpatient services may be conditional or
				  limited.
A. Medically warranted days:
				A general hospital is not reimbursed for days of acute level inpatient services
				furnished to an eligible recipient as a result of difficulty in securing
				alternative placement. A lack of nursing facility placement is not sufficient
				grounds for continued acute-level hospital care.
B. Awaiting placement days:
(1) When the MAD utilization review (UR)
				contractor determines that an eligible recipient no longer meets the care
				criteria in a rehabilitation, extended care or other specialty hospital or PPS
				exempt rehabilitation hospital but requires a nursing facility level of care
				which may not be immediately located, those days during which the eligible
				recipient is awaiting placement in a lower level of care facility are termed
				"awaiting placement days". Payment to the hospital for awaiting placement days
				is made at the weighted average rate paid by MAD for the level of nursing
				facility services required by the eligible recipient (high NF or low
				NF).
(2) When the MAD UR contractor
				determines that a recipient under 21 years of age no longer meets acute care
				criteria and it is verified that an appropriate reviewing authority has made a
				determination that the eligible recipient requires a residential level of care
				which may not be immediately located, those days during which the eligible
				recipient is awaiting placement to the lower level of care are termed "awaiting
				placement days". MAD does not cover residential care for individuals over 21
				years of age.
(3) Payment to the
				hospital for awaiting placement days is made at the weighted average rate paid
				by MAD for residential services that may have different levels of
				classification based on the medical necessity for the placement of the eligible
				recipient. See 8.302.5 NMAC,
Prior Authorization and Utilization
				Review.
A separate claim form must be submitted for awaiting placement
				days.
(4) MAD does not pay for any
				ancillary services for "awaiting placement days". The rate paid is considered
				all inclusive. Medically necessary physician visits or
,
in the
				case of the eligible recipient under 21 years of age requiring residential
				services, licensed Ph.D. psychologist visits, are not included in this
				limitations.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 311 - HOSPITAL SERVICES › Part 2 - HOSPITAL SERVICES › Section 8.311.2.15 - OUTPATIENT SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
MAD covers outpatient services which are medically necessary
				  for prevention, diagnosis or rehabilitation as indicated by the condition of an
				  eligible recipient.
Services must be furnished within the scope and practice of a
				  professional provider as defined by state laws and regulations.
A. Outpatient covered services: Covered
				hospital outpatient care includes the use of minor surgery or cast rooms,
				intravenous infusions, catheter changes, first aid care of injuries, laboratory
				and radiology services, and diagnostic and therapeutic radiation, including
				radioactive isotopes. A partial hospitalization program in a general hospital
				psychiatric unit is considered under outpatient services. See 8.321.5 NMAC,
Outpatient Psychiatric Services and Partial
				Hospitalization
.
B.
				Outpatient noncovered services: MAD does not cover the following specific
				outpatient benefits:
(1) outpatient hospital
				services not considered medically necessary for the condition of the eligible
				recipient;
(2) outpatient hospital
				services that require prior approval for which the approval was not requested
				except in cases with extenuating circumstances as granted by MAD or its
				designee;
(3) outpatient hospital
				services furnished to an individual who was not eligible for MAD services on
				the date of service;
(4)
				experimental or investigational procedures, technologies or therapies and the
				services related to them, including hospitalization, anesthesiology, laboratory
				tests, and imaging services; see 8.325.6 NMAC,
Experimental or
				Investigational Procedures or Therapies
;
(5) drugs classified as "ineffective" by the
				federal food and drug administration;
(6) laboratory specimen handling or mailing
				charges; and
(7) formal educational
				or vocational services which relate to traditional academic subjects or
				training for employment.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 311 - HOSPITAL SERVICES › Part 3 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT - INPATIENT HOSPITAL SERVICES › Section 8.311.3.3 - 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 the Social Security Act as
				  amended or by state statute. See Section 27-2-12
et seq
NMSA
				  1978. Section 9-8-1 et seq. NMSA 1978 establishes the health care authority
				  (HCA) as a single, unified department to administer laws and exercise functions
				  relating to health care facility licensure and health care purchasing and
				  regulation.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 311 - HOSPITAL SERVICES › Part 3 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT - INPATIENT HOSPITAL SERVICES › Section 8.311.3.5 - EFFECTIVE DATE

Current through Register Vol. 35, No. 13, July 16, 2024
June 1, 2016, unless a later date is cited at the end of a
				  section.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 311 - HOSPITAL SERVICES › Part 3 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT - INPATIENT HOSPITAL SERVICES › Section 8.311.3.6 - OBJECTIVE

Current through Register Vol. 35, No. 13, July 16, 2024
The objective of this rule is to provide instructions for the
				  service portion of the New Mexico medical assistance
				  programs.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 311 - HOSPITAL SERVICES › Part 3 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT - INPATIENT HOSPITAL SERVICES › Section 8.311.3.8 - 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 311 - HOSPITAL SERVICES › Part 3 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT - INPATIENT HOSPITAL SERVICES › Section 8.311.3.9 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES - INPATIENT HOSPITAL SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
The New Mexico title XIX program reimburses appropriately
				  licensed and certified acute care hospitals for inpatient services as outlined
				  in this part. Procedures and policies governing state licensure, certification
				  of providers, utilization review and any other aspect of state regulation of
				  the title XIX program not relating to the method of computing payment rates for
				  inpatient services are not affected by this part.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 311 - HOSPITAL SERVICES › Part 3 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT - INPATIENT HOSPITAL SERVICES › Section 8.311.3.11 - PAYMENT METHODOLOGY FOR PPS- EXEMPT HOSPITALS AND EXEMPT UNITS WITHIN HOSPITALS

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Application of TEFRA principles of reimbursement:
(1) The principles and methods identified in
				Public Law 97-248 provision (TEFRA), effective October 1, 1982, regarding
				allowable payment for inpatient hospital services, and any subsequent changes
				to such provision shall be used to determine:
(a) the amount payable by the department
				through its fiscal agent for services covered under the MAD program and
				provided to eligible recipients; and
(b) the manner of payment and the manner of
				settlement or overpayments and underpayment for inpatient services provided by
				hospitals for MAD reimbursement purposes, effective for all accounting periods
				which begin on or after October 1, 1983.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 311 - HOSPITAL SERVICES › Part 3 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT - INPATIENT HOSPITAL SERVICES › Section 8.311.3.12 - PROSPECTIVE PAYMENT METHODOLOGY FOR HOSPITALS

Current through Register Vol. 35, No. 13, July 16, 2024
Payment for all covered inpatient services rendered to
				  eligible recipients admitted to acute care hospitals (other than those
				  identified in Subsections C through D of
				  8.311.3.10
				  NMAC) on or after October 1, 1989 shall be made based on a prospective payment
				  approach which compensates hospitals an amount per discharge for discharges
				  classified according to the diagnosis related group (DRG) methodology. The
				  prospective rates for each hospital's MAD discharges will be determined by the
				  department in the manner described in the following subsections.
A.
Services included in or excluded
				from the prospective payment rate:
(1)
				Prospective payment rates shall constitute payment in full for each MAD
				discharge. Hospitals may not separately bill the eligible recipient or the MAD
				program for medical services rendered during an inpatient stay, except as
				described below. Hospitals may submit a claim for payment only upon the final
				discharge of an eligible recipient or upon completion of the transfer of the
				eligible recipient to another acute care hospital.
(2) The prospective payment rate shall
				include all services provided to hospital inpatients. These services shall
				include all items and non-physician services furnished directly or indirectly
				to hospital inpatients, such as:
(a)
				laboratory services;
(b) pacemakers
				and other prosthetic devices, including lenses and artificial limbs, knees and
				hips;
(c) radiology services,
				including computed tomography (CT) or magnetic resonance imaging (MRI) scans
				furnished to an eligible recipient by a physician's office, other hospital or
				radiology clinic;
(d)
				transportation (including transportation by ambulance) to and from another
				hospital or freestanding facility to receive specialized diagnostic or
				therapeutic services.
(3) Services which may be billed separately
				include:
(a) ambulance service when the
				eligible recipient is transferred from one hospital to another and is admitted
				as an inpatient to the second hospital;
(b) physician services furnished to an
				individual eligible recipient.