reglab/statecodes huggingface dataset:
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 6 - CASE MANAGEMENT SERVICES FOR CHILDREN UP TO AGE THREE › Section 8.326.6.9 - CASE MANAGEMENT SERVICES FOR CHILDREN UP TO AGE THREE

Current through Register Vol. 35, No. 13, July 16, 2024
The New Mexico medical assistance program (medicaid) pays for
				  medically necessary health services furnished to eligible recipients, including
				  case management services furnished to medicaid eligible children up to the age
				  of three (3) who are medically at risk due to family conditions [
				  42 U.S.C. Section
				  1396 n(g)(1)(2) ]. This part describes
				  eligible providers, eligible recipients, covered services, service limitations
				  and general reimbursement methodology.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 6 - CASE MANAGEMENT SERVICES FOR CHILDREN UP TO AGE THREE › Section 8.326.6.10 - ELIGIBLE PROVIDERS

Current through Register Vol. 35, No. 13, July 16, 2024
A. Upon
				approval of New Mexico medical assistance program provider participation
				agreements by the New Mexico medical assistance division (MAD), the following
				certified agencies are eligible to be reimbursed for furnishing case management
				services to children up to the age of three (3) who are medically at risk due
				to family conditions:
(1) public health
				offices of the New Mexico department of health;
(2) Indian tribal governments or Indian
				health services;
(3) federally
				qualified health centers (FQHC); and
(4) other community-based agencies which meet
				the requirements for participation.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 6 - CASE MANAGEMENT SERVICES FOR CHILDREN UP TO AGE THREE › Section 8.326.6.11 - PROVIDER RESPONSIBILITIES

Current through Register Vol. 35, No. 13, July 16, 2024
Providers who furnish services to medicaid recipients must
				  comply with all specified medicaid participation requirements. See 8.302.1
				  NMAC,
General Provider Policies
. Providers must verify that
				  individuals are eligible for medicaid at the time services are furnished and
				  determine if medicaid recipients have other health insurance. Providers must
				  maintain records which are sufficient to fully disclose the extent and nature
				  of the services furnished to recipients. See 8.302.1 NMAC,
General
				  Provider Policies
. Documentation must substantiate the date of
				  service, type of contact, category of case management service furnished,
				  length/time units of service furnished, nature/content of the service
				  furnished, result of service or intended result and relationship of the service
				  furnished to goals identified in the individual service plan.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 6 - CASE MANAGEMENT SERVICES FOR CHILDREN UP TO AGE THREE › Section 8.326.6.12 - ELIGIBLE RECIPIENTS

Current through Register Vol. 35, No. 13, July 16, 2024
Case management services are available to medicaid eligible
				  children under the age of three (3) who are medically at risk due to family
				  conditions but who are not developmentally delayed.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 6 - CASE MANAGEMENT SERVICES FOR CHILDREN UP TO AGE THREE › Section 8.326.6.13 - COVERED SERVICES AND SERVICE LIMITATIONS

Current through Register Vol. 35, No. 13, July 16, 2024
Medicaid covers case management services for children up to
				  the age of three (3) which help recipients gain access to medical, social,
				  educational or other needed services. Case management services provide
				  necessary coordination with providers of non-medical services, such as
				  nutrition or education programs, when these services are necessary to enable
				  recipients to benefit from the health services paid for by medicaid.
A. Medicaid covers the following case
				management service activities furnished children up to the age of three (3):
(1) identification of programs appropriate
				for the recipient's needs, including those which teach basic maternal and child
				health skills;
(2) help in
				accessing the identified programs;
(3) assessment of the service needs of
				recipients to coordinate the delivery of services when multiple providers or
				programs are involved in the provision of care;
(4) reassessment to ensure that the services
				which were obtained are necessary and appropriate in meeting the recipient's
				needs; and
(5) determination of
				whether any additional services are warranted.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 6 - CASE MANAGEMENT SERVICES FOR CHILDREN UP TO AGE THREE › Section 8.326.6.14 - NONCOVERED SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
Case management services are subject to the limitations and
				  coverage restrictions which exist for other medicaid services. See 8.301.3
				  NMAC,
General Noncovered Services
. Medicaid does not cover the
				  following specific activities:
A.
				services furnished to individuals who are not medicaid eligible or who are not
				residents of New Mexico;
B.
				services furnished by case managers which are not substantiated with
				appropriate documentation in the recipient's file;
C. formal educational or vocational services
				which are related to traditional academic subjects or job training;
D. outreach and identification activities in
				which providers attempt to contact potential recipients;
E. administrative activities, such as
				medicaid eligibility determinations and intake processing;
F. institutional discharge
				planning;
G. services which are
				furnished by other practitioners, such as therapies, transportation and
				homemaker or personal care services; and
H. services considered by MAD or its designee
				to be excessive based on the needs of the recipient and on the documentation by
				the case manager.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 6 - CASE MANAGEMENT SERVICES FOR CHILDREN UP TO AGE THREE › Section 8.326.6.15 - PLAN OF CARE

Current through Register Vol. 35, No. 13, July 16, 2024
A. Case
				managers develop and implement plans of care for each medicaid recipient. Plans
				of care are developed in consultation with the recipients, families or legal
				guardian(s), physicians and others involved with care.
B. The following must be contained in the
				plan of care or documents used in the development of the plan of care. The plan
				of care and all supporting documentation must be available for review in the
				recipient's file:
(1) statement of the nature
				of the specific problem and needs of the child;
(2) description of the intermediate and
				long-range goals with the projected timetable for their attainment, including
				specific information on the duration and scope of services; and
(3) statement and rationale of the plan of
				treatment for achieving these intermediate and long-range goals, including
				review and modification of the plan.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 6 - CASE MANAGEMENT SERVICES FOR CHILDREN UP TO AGE THREE › Section 8.326.6.16 - PRIOR APPROVAL AND UTILIZATION REVIEW

Current through Register Vol. 35, No. 13, July 16, 2024
All medicaid services are subject to utilization review for
				  medical necessity and program compliance. Reviews can be performed before
				  services are furnished, after services are furnished and before payment is
				  made, or after payment is made. See 8.302.5 NMAC,
Prior Authorization
				  and Utilization Review
. Once enrolled, providers receive instructions
				  and documentation forms necessary for prior approval and claims
				  processing.
A.
Prior
				approval:
Certain procedures or services which are part of the treatment
				plan can require prior approval from MAD or its designee. See utilization
				instruction for those services. Services for which prior approval was obtained
				remain subject to utilization review at any point in the payment
				process.
B.
Eligibility
				determination:
Prior approval of services does not guarantee that
				individuals are eligible for medicaid. Providers must verify that individuals
				are eligible for medicaid at the time services are furnished and determine if
				medicaid recipients have other health insurance.
C.
Reconsideration:
Providers
				who disagree with prior approval request denials or other review decisions can
				request a re-review and a reconsideration. See Section MAD-953,
Reconsideration of Utilization Review Decisions
.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 6 - CASE MANAGEMENT SERVICES FOR CHILDREN UP TO AGE THREE › Section 8.326.6.17 - REIMBURSEMENT

Current through Register Vol. 35, No. 13, July 16, 2024
A. Case management
				providers must submit claims for reimbursement on the HCFA 1500 claim form or
				its successor. See 8.302.2 NMAC,
Billing for Medicaid
				Services
. Instructions on documentation, billing and claims processing
				are sent to approved medicaid providers. Reimbursement for case management
				services is made at the lesser of the following:
(1) the provider's billed charge;
				or
(2) the MAD fee schedule for the
				specific service or procedure.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 7 - ADULT PROTECTIVE SERVICES CASE MANAGEMENT › Section 8.326.7.3 - STATUTORY AUTHORITY

Current through Register Vol. 35, No. 13, July 16, 2024
The New Mexico medicaid program is administered pursuant to
				  regulations promulgated by the federal department of health and human services
				  under Title XIX of the Social Security Act, as amended and by the state health
				  care authority pursuant to state statute. See Section 27-2-12 et seq. NMSA 1978
				  (Repl. Pamp. 1991). Section 9-8-1 et seq. NMSA 1978 establishes the health care
				  authority (HCA) as a single, unified department to administer laws and exercise
				  functions relating to health care facility licensure and health care purchasing
				  and regulation.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 7 - ADULT PROTECTIVE SERVICES CASE MANAGEMENT › Section 8.326.7.6 - OBJECTIVE

Current through Register Vol. 35, No. 13, July 16, 2024
The objective of these regulations is to provide policies for
				  the service portion of the New Mexico medicaid program. These policies describe
				  eligible providers, covered services, noncovered services, utilization review,
				  and provider reimbursement.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 7 - ADULT PROTECTIVE SERVICES CASE MANAGEMENT › Section 8.326.7.8 - MISSION STATEMENT

Current through Register Vol. 35, No. 13, July 16, 2024
The mission of the New Mexico medical assistance division
				  (MAD) is to maximize the health status of medicaid-eligible individuals by
				  furnishing payment for quality health services at levels comparable to private
				  health plans.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 7 - ADULT PROTECTIVE SERVICES CASE MANAGEMENT › Section 8.326.7.9 - ADULT PROTECTIVE SERVICES CASE MANAGEMENT

Current through Register Vol. 35, No. 13, July 16, 2024
The New Mexico medical assistance program (medicaid) pays for
				  medically necessary health services furnished to eligible recipients, including
				  case management services furnished to medicaid eligible adults, individuals who
				  are 18 years or older, who have been neglected, abused, or exploited [ 42
				  U.S.C. Section 136 n(g)(1)(2) ]. This part describes eligible providers,
				  eligible population, covered services, service limitations, and general
				  reimbursement information.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 7 - ADULT PROTECTIVE SERVICES CASE MANAGEMENT › Section 8.326.7.10 - ELIGIBLE PROVIDERS

Current through Register Vol. 35, No. 13, July 16, 2024
A. Upon
				approval of New Mexico medical assistance program provider participation
				agreements by the New Mexico medical assistance division (MAD), the following
				agencies are eligible to be reimbursed for furnishing case management services
				to an eligible recipient.
(1) Government
				agencies or their delegates which by law receive reports or allegations of
				abuse, exploitation or neglect and who by New Mexico state law are required to
				provide adult protective services for the target population.
(2) Once enrolled, providers receive a packet
				of information, including medicaid program policies, billing instructions,
				utilization review instructions and other pertinent material from MAD.
				Providers are responsible for ensuring that they have received these materials
				and for updating them as new materials are received from MAD.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 7 - ADULT PROTECTIVE SERVICES CASE MANAGEMENT › Section 8.326.7.11 - PROVIDER RESPONSIBILITIES

Current through Register Vol. 35, No. 13, July 16, 2024
Providers who furnish services to medicaid recipients must
				  comply with all specified medicaid participation requirements. See 8.302.1
				  NMAC,
General Provider Policies
. Providers must verify that
				  individuals are eligible for medicaid at the time services are furnished and
				  determine if medicaid recipients have other health insurance. Providers must
				  maintain records which are sufficient to fully disclose the extent and nature
				  of the services furnished to recipients. See 8.302.1 NMAC,
General
				  Provider Policies
. Documentation must substantiate the date of
				  services, type of contact, category of case management services furnished,
				  length/time units of service furnished, nature/content of the service
				  furnished, result of service or intended result and relationship of the service
				  furnished to the goals identified in the individual service
				  plan.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 7 - ADULT PROTECTIVE SERVICES CASE MANAGEMENT › Section 8.326.7.12 - ELIGIBLE RECIPIENTS

Current through Register Vol. 35, No. 13, July 16, 2024
Case management services are available for eligible medicaid
				  recipients who meet all of the following criteria:
A. individuals who are eighteen (18) years of
				age or older;
B. individuals who
				are residents of the state of New Mexico;
C. individuals who are not residents of an
				institution; and
D. individuals who
				through investigation are found to be abused, neglected or exploited; abuse is
				defined as knowingly, intentionally or negligently and without justifiable
				cause inflicting physical pain, injury or mental anguish, or the intentional
				deprivation by a caretaker or other person of services necessary to maintain
				the mental and physical health of an adult; neglect is defined as failure of
				the caretaker of an adult to provide basic needs such as clothing, food,
				shelter, supervision and care for the physical and mental health for that adult
				or failure by an adult to provide such basic needs for him/herself;
				exploitation is defined as an unjust or improper use of an adult's resources
				for another's profit or advantage, pecuniary or otherwise.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 7 - ADULT PROTECTIVE SERVICES CASE MANAGEMENT › Section 8.326.7.13 - COVERED SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
Medicaid covers the following case management services for
				  adults who have been abused, neglected or exploited:
A. services which help recipients gain access
				to medical, social, educational or other needed services.
B. assessment of a recipient's medical and
				social needs and functional limitations using standardized needs assessment
				instruments;
C. development and
				implementation of an individualized plan of care designed to help recipients
				retain or achieve the maximum degree of independence;
D. mobilization of the use of "natural
				helping" networks such as family members, church members, community
				organizations, support groups and friends; and
E. coordination and monitoring of the
				delivery of services, evaluation of the effectiveness and quality of the
				services, and revision of the plan of care, if necessary.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 7 - ADULT PROTECTIVE SERVICES CASE MANAGEMENT › Section 8.326.7.14 - NONCOVERED SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
Case management services are subject to the limitations and
				  coverage restrictions which exist for other medicaid services. See 8.301.3
				  NMAC,
General Noncovered Services
. Medicaid does not cover the
				  following specific services as adult protective services case
				  management:
A. services furnished to
				individuals who are not medicaid eligible or who do not meet the definition of
				an adult who is abused, neglected or exploited;
B. services furnished by case managers which
				are not substantiated with appropriate documentation in the recipient's
				file;
C. formal educational or
				vocation services related to traditional academic subjects or vocational
				training;
D. client outreach
				activities in which a provider attempts to contact potential
				recipients;
E. administrative
				activities, such as medicaid eligibility determinations and intake
				processing;
F. case management for
				a recipient who is institutionalized, except for the last thirty (30) days of
				the institutionalization to ensure follow-up services;
G. institutional discharge planning which is
				a required condition for payment of hospital, nursing home or residential
				treatment center services;
H.
				services which are furnished under other categories, such as therapies,
				transportation or counseling; or
I.
				services considered by MAD or its designee to be excessive based on the needs
				of the recipient and documentation in the case management file.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 7 - ADULT PROTECTIVE SERVICES CASE MANAGEMENT › Section 8.326.7.15 - PLAN OF CARE

Current through Register Vol. 35, No. 13, July 16, 2024
A. Case
				managers develop and implement plans of care for each medicaid recipient. Plans
				of care are developed in consultation and cooperation with recipients, families
				or legal guardian(s), primary physicians, as appropriate and others involved
				with the recipient's care.
B. The
				following must be contained in the treatment plan or documents used in the
				development of the treatment plan. The treatment plan and all supporting
				documentation must be available for review in the recipient's file:
(1) statement of the nature of the specific
				problem and the specific needs of the recipient;
(2) description of the functional level of
				the recipient, including the following:
(a)
				mental status assessment;
(b)
				intellectual function assessment;
(c) psychological assessment;
(d) educational assessment;
(e) vocational assessment;
(f) social assessment;
(g) medical assessment; and
(h) physical assessment.
(3) description of the intermediate and
				long-range goals, with the projected timetable for their attainment and
				duration and scope of services; and
(4) statement and rationale of the treatment
				plan for achieving these intermediate and long-range goals, including
				provisions for review and modification of the plan and plans for
				discontinuation of services, criteria for discontinuation of services and
				projected date service will be discontinued.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 7 - ADULT PROTECTIVE SERVICES CASE MANAGEMENT › Section 8.326.7.16 - PRIOR APPROVAL AND UTILIZATION REVIEW

Current through Register Vol. 35, No. 13, July 16, 2024
All medicaid services are subject to utilization review for
				  medical necessity and program compliance. Reviews can be performed before
				  services are furnished, after services are furnished and before payment is
				  made, or after payment is made. See 8.302.5 NMAC,
Prior Authorization
				  and Utilization Review
. Once enrolled, providers receive instructions
				  and documentation forms necessary for prior approval and claims
				  processing.
A.
Prior
				approval:
Certain procedures or services which are specified in the
				treatment plan can require prior approval from MAD or its designee. Services
				for which prior approval was obtained remain subject to utilization review at
				any point in the payment process.
B.
Eligibility determination:
Prior approval of services does not guarantee that individuals are eligible for
				medicaid. Providers must verify that individuals are eligible for medicaid at
				the time services are furnished and determine if medicaid recipients have other
				health insurance.
C.
Reconsideration:
Providers who disagree with prior approval
				request denials or other review decisions can request a re-review and a
				reconsideration. See Section MAD-953,
Reconsideration of Utilization
				Review Decisions
.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 7 - ADULT PROTECTIVE SERVICES CASE MANAGEMENT › Section 8.326.7.17 - REIMBURSEMENT

Current through Register Vol. 35, No. 13, July 16, 2024
A. Case management
				providers must submit claims for reimbursement on the HCFA-1500 claim form or
				its successor. See 8.302.2 NMAC,
Billing for Medicaid
				Services
. Once enrolled, instructions on documentation, billing and
				claims processing are sent to the medicaid providers. Reimbursement for case
				management providers is made at the lesser of the following:
(1) the provider's billed charge;
				or
(2) the MAD fee schedule for the
				specific service.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 8 - CASE MANAGEMENT SERVICES FOR CHILDREN PROVIDED BY JUVENILE PROBATION AND PAROLE OFFICERS › Section 8.326.8.3 - STATUTORY AUTHORITY

Current through Register Vol. 35, No. 13, July 16, 2024
The New Mexico medicaid program is administered pursuant to
				  regulations promulgated by the federal department of health and human services
				  under Title XIX of the Social Security Act, as amended and by the state health
				  care authority pursuant to state statute. See Section 27-2-12 et seq. NMSA 1978
				  (Repl. Pamp. 1991). Section 9-8-1 et seq. NMSA 1978 establishes the health care
				  authority (HCA) as a single, unified department to administer laws and exercise
				  functions relating to health care facility licensure and health care purchasing
				  and regulation.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 8 - CASE MANAGEMENT SERVICES FOR CHILDREN PROVIDED BY JUVENILE PROBATION AND PAROLE OFFICERS › Section 8.326.8.6 - OBJECTIVE

Current through Register Vol. 35, No. 13, July 16, 2024
The objective of these regulations is to provide policies for
				  the service portion of the New Mexico medicaid program. These policies describe
				  eligible providers, covered services, noncovered services, utilization review,
				  and provider reimbursement.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 8 - CASE MANAGEMENT SERVICES FOR CHILDREN PROVIDED BY JUVENILE PROBATION AND PAROLE OFFICERS › Section 8.326.8.8 - MISSION STATEMENT

Current through Register Vol. 35, No. 13, July 16, 2024
The mission of the New Mexico medical assistance division
				  (MAD) is to maximize the health status of medicaid-eligible individuals by
				  furnishing payment for quality health services at levels comparable to private
				  health plans.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 8 - CASE MANAGEMENT SERVICES FOR CHILDREN PROVIDED BY JUVENILE PROBATION AND PAROLE OFFICERS › Section 8.326.8.9 - CASE MANAGEMENT SERVICES FOR CHILDREN PROVIDED BY JUVENILE PROBATION AND PAROLE OFFICERS

Current through Register Vol. 35, No. 13, July 16, 2024
The New Mexico human services department (HSD) pays for
				  medically necessary case management services furnished to identified clients
				  under nineteen (19) years of age who are under the supervision of a juvenile
				  probation and parole officer (JPPO) and have an identified physical or mental
				  condition which has a high probability of impairing their cognitive, emotional,
				  neurological, social or physical development. See Section 1915(g) of the Social
				  Security Act. This part describes eligible providers, eligible clients, covered
				  services, service restrictions and general reimbursement
				  methodology.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 8 - CASE MANAGEMENT SERVICES FOR CHILDREN PROVIDED BY JUVENILE PROBATION AND PAROLE OFFICERS › Section 8.326.8.10 - ELIGIBLE PROVIDERS

Current through Register Vol. 35, No. 13, July 16, 2024
Upon approval of a New Mexico medical assistance program
				  provider participation agreement by the New Mexico medical assistance division
				  (MAD), the following agency is reimbursed for furnishing case management
				  services to clients in the identified population: New Mexico children, youth
				  and families department. See the New Mexico Children's Code, Chapter
				  32A-2-5.
A.
Agency
				qualifications:
B.
Case manager qualification:
(1)
				Case managers employed by the New Mexico children, youth and families
				department must possess the knowledge, skills, abilities and experience to
				perform case management services for the targeted population and when
				necessary, possess language skills, cultural sensitivity and acquired knowledge
				unique to a geographic area. Case managers must meet at least one of the
				following qualifications: a bachelor's degree in social work, counseling,
				psychology or a related field and experience serving the targeted
				population.
(2) All children, youth
				and families department, juvenile probation and parole officers (JPPOs) and
				JPPO supervisors performing targeted case management services must have
				documentation in their personnel file of completion of structured decision
				making training and any other additional or supplemental training developed by
				CYFD specific for this program.
(3)
				Once enrolled, providers receive a packet of information, including medicaid
				program policies, billing instructions, utilization review instructions and
				other pertinent material from MAD. Providers are responsible for ensuring that
				they have received these materials and for updating them as new materials are
				received from MAD.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 8 - CASE MANAGEMENT SERVICES FOR CHILDREN PROVIDED BY JUVENILE PROBATION AND PAROLE OFFICERS › Section 8.326.8.11 - PROVIDER RESPONSIBILITIES

Current through Register Vol. 35, No. 13, July 16, 2024
Providers who furnish services to medicaid clients must
				  comply with all specified medicaid participation requirements. See 8.302.1
				  NMAC,
General Provider Policies
. Providers must verify that
				  individuals are eligible for medicaid at the time services are furnished and
				  determine if medicaid clients have other health insurance. Providers must
				  maintain records which are sufficient to fully disclose the extent and nature
				  of the services furnished to clients. See 8.302.1 NMAC,
General
				  Provider Policies
. Documentation must substantiate the date of
				  service, nature of contact, reason the service was furnished, nature/content of
				  the service furnished, result of service or intended result and relationship of
				  the service furnished to goals identified in the plan of
				  care.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 8 - CASE MANAGEMENT SERVICES FOR CHILDREN PROVIDED BY JUVENILE PROBATION AND PAROLE OFFICERS › Section 8.326.8.12 - ELIGIBLE RECIPIENTS (TARGET POPULATION)

Current through Register Vol. 35, No. 13, July 16, 2024
Medicaid covers case management services furnished to
				  medicaid clients under nineteen (19) years of age who are involved with the
				  juvenile justice system or who have committed a delinquent act and have an
				  identified physical or mental condition which has a high probability of
				  impairing their cognitive, emotional, neurological, social or physical
				  development. Juveniles who are adjudicated and incarcerated or who are placed
				  in a detention center for longer than sixty (60) pre-adjudication days) are not
				  eligible for medicaid and/or case management services paid for by
				  medicaid.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 8 - CASE MANAGEMENT SERVICES FOR CHILDREN PROVIDED BY JUVENILE PROBATION AND PAROLE OFFICERS › Section 8.326.8.13 - COVERED SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
Case management is defined as services which assist clients
				  in the target population in gaining access to needed medical, social,
				  educational and other services.
A.
				Medicaid covers the following case management service activities for clients in
				the target population:
(1) assessment of the
				client's medical, social, educational and other service needs and functional
				limitations using standardized needs assessment instruments;
(2) development and implementation of
				individualized plan of care;
(3)
				mobilizing the use of "natural helping" networks, such as family members,
				church members and friends;
(4)
				development of increased opportunities for community access and involvement
				including assistance in the location of housing, community living skills,
				vocational, social, educational or other service programs;
(5) coordination and monitoring of the
				delivery of services; and
(6)
				evaluation of the effectiveness of services furnished under the plan of care
				and revision of the plan as conditions warrant.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 8 - CASE MANAGEMENT SERVICES FOR CHILDREN PROVIDED BY JUVENILE PROBATION AND PAROLE OFFICERS › Section 8.326.8.14 - NONCOVERED SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
Case management services are subject to the limitations and
				  coverage restrictions which exist for other medicaid services. See 8.301.3
				  NMAC,
General Noncovered Services
. In addition, medicaid does
				  not cover the following specific activities:
A. services furnished to individuals who are
				not medicaid eligible or who are not eligible for these services;
B. services furnished by case managers which
				are not substantiated with appropriate documentation in the client's
				file;
C. formal educational or
				vocational services related to traditional academic subjects or job
				training;
D. outreach and
				identification activities in which providers attempt to contact potential
				clients;
E. administrative
				activities, such as medicaid eligibility determinations and intake
				processing;
F. discharge planning
				from inpatient hospital, residential facility or community-based
				placement;
G. services which are
				furnished under other categories, such as therapies, transportation or
				counseling;
H. services provided to
				clients that are not part of the target population or services which are not
				documented in the client file; or
I. services provided to clients that relate
				to the legal and/or corrections functions performed by JPPOs.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 8 - CASE MANAGEMENT SERVICES FOR CHILDREN PROVIDED BY JUVENILE PROBATION AND PAROLE OFFICERS › Section 8.326.8.15 - PLAN OF CARE

Current through Register Vol. 35, No. 13, July 16, 2024
A. Case
				managers develop and implement plans of care in conjunction with the clients,
				families or legal guardian(s), therapists, physicians or others who assist with
				the client's care.
B. The following
				must be contained in the plan of care or documents used in the development of
				the plan of care. The plan of care and all supporting documentation must be
				available for review in the client's file:
(1) statement of the nature of the specific
				problem and the specific needs of the client;
(2) description of the functional level of
				the client, including an assessment and evaluation using the structured
				decision making assessment tool developed by CYFD and approved by HSD or its
				successor.
(3) description of the
				intermediate and long-range goals with the projected timetable for their
				attainment, including information about the duration and scope of
				services;
(4) statement and
				rationale of the plan of treatment for achieving these intermediate and
				long-range goals, including review and modification of the plan.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 8 - CASE MANAGEMENT SERVICES FOR CHILDREN PROVIDED BY JUVENILE PROBATION AND PAROLE OFFICERS › Section 8.326.8.16 - PRIOR APPROVAL AND UTILIZATION REVIEW

Current through Register Vol. 35, No. 13, July 16, 2024
All medicaid services are subject to utilization review for
				  medical necessity and program compliance. Case management services furnished to
				  clients in this targeted population do not require prior approval. Reviews can
				  be performed before services are furnished, after services are furnished and
				  before payment is made, or after payment is made. See 8.302.5 NMAC,
Prior Authorization and Utilization Review
. Once enrolled,
				  providers receive instructions and documentation forms necessary for prior
				  approval and claims processing.
A.
Prior approval:
Certain procedures or services which are part of
				the plan of care can require prior approval from MAD or its designee. See
				utilization instructions for the specific service. Services for which prior
				approval was obtained remain subject to utilization review at any point in the
				payment process.
B.
Eligibility determination:
Prior approval of services does not
				guarantee that individuals are eligible for medicaid. Providers must verify
				that individuals are eligible for medicaid at the time services are furnished
				and determine if medicaid clients have other health insurance.
C.
Reconsideration:
Providers
				who disagree with prior approval request denials or other review decisions can
				request a re-review and a reconsideration. See Section MAD-953,
Reconsideration of Utilization Review Decisions
.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 8 - CASE MANAGEMENT SERVICES FOR CHILDREN PROVIDED BY JUVENILE PROBATION AND PAROLE OFFICERS › Section 8.326.8.17 - REIMBURSEMENT

Current through Register Vol. 35, No. 13, July 16, 2024
Case management providers must submit claims for
				  reimbursement on the HCFA 1500 claim form or its successor. See 8.302.2 NMAC,
Billing for Medicaid Services
. Instructions on documentation,
				  billing and claims processing are sent to approved medicaid providers.
A.
Reimbursement for non-governmental
				providers:
For community agencies, tribal government, or Indian health
				services, reimbursement for case management services is made at the lesser of
				the following:
(1) the provider's billed
				charge; or
(2) the MAD fee schedule
				for the specific service or procedure.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 10 - BRAIN INJURY SERVICES FUND PROGRAM › Section 8.326.10.3 - STATUTORY AUTHORITY

Current through Register Vol. 35, No. 13, July 16, 2024
Subsection E of Section 9-23-6 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 326 - CASE MANAGEMENT SERVICES › Part 10 - BRAIN INJURY SERVICES FUND PROGRAM › Section 8.326.10.5 - EFFECTIVE DATE

Current through Register Vol. 35, No. 13, July 16, 2024
April 1, 2021, unless a later date is cited at the end of a
				  section.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 10 - BRAIN INJURY SERVICES FUND PROGRAM › Section 8.326.10.6 - OBJECTIVE

Current through Register Vol. 35, No. 13, July 16, 2024
The objective of this rule is to establish policies and
				  procedures and define standards of the New Mexico human services department
				  (HSD) brain injury services fund program. The brain injury services fund
				  program provides timely short term in-state non-medicaid services for persons
				  with qualifying brain injuries that are of traumatic or other acquired origin
				  in order to promote independence and to assist the individual in resolving a
				  brain-injury related crisis need and access available payer sources and
				  community resources, when there is no other funding
				  available.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 10 - BRAIN INJURY SERVICES FUND PROGRAM › Section 8.326.10.8 - MISSION STATEMENT

Current through Register Vol. 35, No. 13, July 16, 2024
To transform lives. Working with our partners, we design and
				  deliver innovative, high quality health and human services that improve the
				  security and promote independence for New Mexicans in their
				  communities.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 10 - BRAIN INJURY SERVICES FUND PROGRAM › Section 8.326.10.9 - BISF ELIGIBILITY REQUIREMENTS

Current through Register Vol. 35, No. 13, July 16, 2024
Enrollment into the BISF, as a non-entitlement program, is
				  on a voluntary basis and occurs in up to six month increments. To be eligible
				  for the BISF program, an applicant with a crisis need must meet the following
				  requirements:
A.
Diagnosis:
Individuals are eligible for BISF services if they have
				a qualifying diagnosis of brain injury of ABI or TBI which has been documented
				in writing by a duly licensed medical professional or psychologist. A
				qualifying diagnosis of brain injury is confirmed by the licensed health
				practitioner's assignment of the current international classification of
				diseases (ICD) code.
B.
Residency:
Eligible individuals must be legal residents of the
				state of New Mexico. Eligible participants must be able to produce
				documentation of the physical location of their New Mexico residence. Those
				residing in an institution or are in the process of transitioning to an
				institutional setting are not eligible for services through the BISF program.
				Those participants who have a confirmed discharge date from an institutional
				setting and are transitioning into the community are eligible for BISF services
				for a 30-day period prior to the planned discharge date to assist with setting
				up needed supports and services. For homeless participants with brain injury,
				the physical address constitutes the agreed-upon location at which the
				participant routinely meets with the BISF service coordinator and at least one
				other community case manager, if available.
C.
Service Coordination
				Duplication:
Those participants served by other service coordination
				programs, care coordination or case management systems are not eligible to
				receive service coordination through the BISF program, unless transitioning
				between programs and with HSD approval. Such programs might include comparable
				services offered through any of the following:
(1) medicaid managed care organization (MCO),
				including community benefit;
(2)
				medicaid home and community-based services waivers;
(3) early and periodic screening, diagnosis
				and treatment;
(4) family infant
				toddler;
(5) program of
				all-inclusive care for the elderly (PACE);
(6) health management organizations (HMOs);
				and
(7) other private
				insurances.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 10 - BRAIN INJURY SERVICES FUND PROGRAM › Section 8.326.10.10 - BISF CONTRACTED ENTITIES AND CONTRACTORS

Current through Register Vol. 35, No. 13, July 16, 2024
Brain injury services fund (BISF) services are provided
				  through two contractor components, service coordination and fiscal intermediary
				  agent for BISF HCBS.
A.
Service
				coordination services:
Service coordination services serve a
				problem-solving function. They are intended to resolve a participant's stated
				crisis need, ensure service continuity, prevent fragmentation of services and
				endeavor to tap into any and all resources that are appropriate and accessible,
				including community-based supports, while resolving the crisis that brought the
				participant into the program. The intent of service coordination is to augment,
				not replace, the participant's natural supports in a manner that facilitates
				independent living and self-determination. All participants must have a BISF
				program service coordinator before they can receive any other BISF program
				services.
(1)
Qualifications for
				service coordination:
Service coordination agencies serving the BISF
				program must ensure the following pertaining to staff qualifications:
(a) have a current social worker license in
				good standing with the New Mexico board of social work examiners; or
(b) have a current registered nurse license,
				in good standing from the New Mexico board of nursing; or
(c) have a bachelor's degree in social work,
				counseling, nursing, special education or closely related field plus one-year
				clinical experience related to the brain injury population working in any of
				the following settings:
(i) home health or
				community health program;
(ii)
				hospital;
(iii) private
				practice;
(iv) publicly funded
				institution or long-term care program;
(v) mental health program;
(vi) school or school health
				setting;
(vii) community-based
				social service program; or
(viii)
				other programs addressing the needs of individuals with brain injury.
(d) With prior approval from the
				HSD BISF program manager or designee, exceptions to service coordinator
				qualifications can be made; contractors requesting qualification exceptions
				must demonstrate that applicant candidates have relevant education, internships
				or volunteer experience. Other qualifications may be:
(i) associates degree and a minimum of three
				years of experience in the mental health or brain injury field; or
(ii) high school graduation or general
				educational development (GED) test and a minimum of five years of experience in
				the mental health or brain injury field.
(e) All BISF service coordinators whether
				subcontracting or employed by a BISF program contracted agency must meet these
				requirements and attend continuing education as determined by HSD.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 10 - BRAIN INJURY SERVICES FUND PROGRAM › Section 8.326.10.11 - CONFLICT OF INTEREST

Current through Register Vol. 35, No. 13, July 16, 2024
Contracted entities and providers, who provide direct BISF
				  services, must avoid conflict of interest or duplication of services and may
				  not:
A. provide direct intervention
				services, such as individual therapy, group therapy, support groups, homemaker
				services, personal attendant services, life skills coaching services,
				psychosocial rehabilitation services, or duplicate BISF HCBS or fiscal
				intermediary services for enrolled BISF participants, when they are also
				contracted to provide service coordination services;
B. accept gifts from existing or potential
				vendors in exchange for a contract relationship or other favorable
				treatment;
C. charge BISF program
				participants for their services; and
D. in no instance shall a service
				coordination agency or fiscal intermediary agent, contracted by HSD for BISF
				program services, direct the provider, vendor or contractor that shall provide
				a participant's services or goods.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 10 - BRAIN INJURY SERVICES FUND PROGRAM › Section 8.326.10.12 - INDEPENDENT LIVING PLAN

Current through Register Vol. 35, No. 13, July 16, 2024
An independent living plan (ILP) is required for each
				  interim service period that includes all the services, goods, and supports
				  recommended to the participant including referrals to BISF HCBS and any other
				  potential resources available in the local community that are needed to resolve
				  the identified crisis. BISF HCBS cannot be initiated until the service
				  coordinator has included the services in the ILP and completed the appropriate
				  referrals. The ILP is to be written and developed by the service coordinator
				  with the participation of the participant and shall include:
A. person-centered goals and action steps
				needed to complete goals;
B.
				education and support necessary to reach goals and objectives;
C. number of hours per month the participant
				will receive BISF service coordination and other identified BISF
				services;
D. expected measurable
				outcomes;
E. time frames for
				reaching goals and meeting objectives;
F. plans for discharge or transference to
				another program or payer source;
G.
				identification of all persons, services or products necessary to reach the
				participant's goals and accomplish their objectives; and
H. estimation of cost of services or goods
				provided by HCBS.