New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 310 - HEALTH CARE PROFESSIONAL SERVICES › Part 10 - HEALTH HOME SERVICES › Section 8.310.10.16 - PAYMENT FOR SERVICES AND BILLING INSTRUCTION

Current through Register Vol. 35, No. 13, July 16, 2024
CareLink NM services are reimbursed through a
				  per-member-per-month (PMPM) payment to the provider agency. CareLink NM
				  dedicated services are those outlined in 8.310.10.13 NMAC. MAD covered services
				  provided to an eligible recipient including behavioral and physical health
				  services, are billed and reimbursed independent of the PMPM payment to the
				  provider agency. The PMPM reimbursement is paid for CareLink NM services
				  regardless of whether the eligible recipient is a MCO member or enrolled in
				  fee-for-service (FFS). The CareLink NM provider agency is responsible for
				  verifying that the eligible recipient has affirmatively agreed to participate
				  in CareLink NM services, documentation of which should be in a signed statement
				  in the eligible recipient's file, in order to receive reimbursement. PMPM codes
				  will be used to document various CareLink NM services provided to an eligible
				  recipient, and trigger the PMPM reimbursement. To receive reimbursement, the
				  provider agency must fully execute at least one CareLink NM service in a given
				  month, meaning direct contact and interaction with an eligible recipient to
				  deliver comprehensive care management, care coordination and health promotion,
				  comprehensive transitional care, individual and family support services, or
				  referral to community and support services. A non-exhaustive list of actions by
				  a CareLink NM provider agency that fail to meet full execution of a CareLink NM
				  service includes attempting to call or visit an eligible member. For referral
				  to community and support services that may not include direct contact with an
				  eligible recipient, the provider agency must, at a minimum, include a service
				  referral and a follow-up with the service provider after the eligible recipient
				  engagement, in order to receive reimbursement.
A.
Fee-for-service (FFS) reimbursement:
For an eligible recipient who is utilizing FFS benefits, the provider
				agency will submit a PMPM health home code through the fiscal agent's claims
				system when a CareLink NM service is provided to an eligible recipient, which
				will then result in a PMPM payment. The requirement for the provider agency to
				submit a claim for payment allows HSD to ensure that the eligible recipient
				receives the CareLink NM service before payment is made. If a CareLink NM
				service is not provided to an eligible recipient in a given month, the provider
				agency will not receive a PMPM payment. The claims submission also provides
				data to HSD on CareLink NM services rendered and the date of service for
				monitoring and evaluation purposes including outcome and quality
				studies.
B.
Managed care
				reimbursement:
For an eligible recipient who is a member of a MCO, the
				provider agency and the MCO shall negotiate reimbursement at an amount no less
				than the established PMPM rate for a health home.