New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 310 - HEALTH CARE PROFESSIONAL SERVICES › Part 12 - INDIAN HEALTH SERVICE AND TRIBAL 638 FACILITIES › Section 8.310.12.12 - COVERED SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
MAD covers medically necessary services and procedures for
				  the diagnosis and treatment of an illness or injury as indicated by the
				  eligible recipient's condition. Services must be furnished within the limits of
				  MAD rules and within the scope of practice of the provider's professional
				  standards. Public health services including services by public health nurses
				  are covered to the same extent their services would be covered for non-IHS
				  public health facilities. Limitations on covered services based on age and
				  category of eligibility also apply to services rendered at an IHS or tribal 638
				  facility. Examples include enhanced benefits only available to early and
				  periodic screening, diagnostic and treatment (EPSDT) eligible recipients, and
				  limitations and enhanced services for alternative benefit plan (ABP) eligible
				  recipients and eligible recipient pregnant women.
A.
Outpatient encounters and
				visits:
An outpatient encounter or visit is face-to-face contact between
				a practitioner and an eligible recipient as documented in the eligible
				recipient's physical or behavioral health record. An encounter or visit can
				occur at an IHS facility, tribal 638 facility, or a MAD recognized offsite
				location including IHS or tribal facility-based services that are provided in
				the home or in community centers or other locations but the medical records and
				the supervision or direction of the service comes from the eligible facility.
				To be billable as an encounter, the eligible recipient must be seen by a level
				of practitioner who would be eligible to be enrolled as a MAD provider or a
				practitioner comparable to that required by other service and provider rules or
				the service must be supervised by a level of practitioner who would be eligible
				to be enrolled as a MAD provider or a practitioner comparable to that required
				by other service and provider rules. Examples include but are not limited to
				the following: audiologist, behavioral health professional, certified nurse
				midwife, certified nurse practitioner, clinical nurse specialist, clinical
				pharmacy specialist, dentist, dental hygienist, licensed dietician,
				occupational therapist, optometrist, pharmacist clinician, physician assistant,
				physician, physical therapist, podiatrist, speech therapist and other provider
				types within their scope of practice as designated by MAD; see 8.310.2 NMAC,
				8.310.3 NMAC and 8.321.2 NMAC.
(1) Visits to
				the same facility, on the same day, for the same or related diagnosis
				constitutes a single encounter.
(2)
				Multiple encounters can occur on the same date of service when the services are
				distinct. The following are examples of types of separate encounters:
(a) an eligible recipient receives a service
				that is not associated with the initial encounter and the service provided is
				for a different principal diagnosis; or
(b) an eligible recipient is seen at two
				different facilities (different provider numbers) and one of the facilities is
				unable to provide the necessary services for the diagnosis or treatment of the
				eligible recipient's condition.
(3) An outpatient encounter may be billed
				when a visit consists of services that could be provided in a physician's
				office such as instructions to a diabetic, medication management, and
				anticoagulant management, when provided by a qualified individual as part of a
				facility-based outpatient program if no other related encounter occurs that
				day, similar to how services would be covered for other providers and clinics
				in other MAD service rules.
(4) An
				outpatient encounter may be billed when an eligible recipient returns at a
				later date for a follow up MAD service such as a laboratory, radiology, or
				therapy service which does not require an additional physician visit if no
				other related visit occurs that day.
(5) When a MAD service typically requires
				multiple visits such as orthodontia services, crowns, and dentures, the
				provider may bill an amount for the initial service that includes the standard
				number of encounters for the service are for the standard number of visits,
				similar to how services would be covered for other providers in other MAD
				service rules, or be paid at a fee schedule amounts that closely approximates
				the appropriate payment for multiple services.