reglab/statecodes huggingface dataset:
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 301 - MEDICAID GENERAL BENEFIT DESCRIPTION › Part 6 - CLIENT MEDICAL TRANSPORTATION SERVICES › Section 8.301.6.13 - CLIENT MEDICAL TRANSPORTATION FUND

Current through Register Vol. 35, No. 13, July 16, 2024
In non-emergency situations, an eligible recipient can
				  request reimbursement from the client medical transportation (CMT) fund through
				  their local county ISD office for money they spend on transportation, meals and
				  lodging. For reimbursement from the CMT fund, an eligible recipient must apply
				  for reimbursement within 30-calendar days after the appointment.
A. Information requirements: The following
				information must be furnished to the ISD CMT fund custodian within 30-calendar
				days of the provider visit to receive reimbursement:
(1) submit a letter on the provider's
				stationary which indicates that the eligible recipient kept the appointment(s)
				for which the CMT fund reimbursement is requested; for medical services,
				written receipts confirming the dates of service must be given to the eligible
				recipient for submission to the local county ISD office;
(2) proper referral with original signatures
				and documentation stating that the services are not available within the
				community from the designated MAD medical management provider or MAD primary
				care provider, when a referral is necessary;
(3) verification of current eligibility for a
				MAD service for the month the appointment and travel are made;
(4) certification that free alternative
				transportation services are not available and that the recipient is not
				enrolled in a managed care organization;
(5) verification of mileage; and
(6) documentation justifying a medical
				attendant.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 301 - MEDICAID GENERAL BENEFIT DESCRIPTION › Part 6 - CLIENT MEDICAL TRANSPORTATION SERVICES › Section 8.301.6.14 - CMT REIMBURSEMENT RATES

Current through Register Vol. 35, No. 13, July 16, 2024
Reimbursement for lodging and meal expenses is based on the
				  MAD allowable fee schedule. The CMT fund reimbursement rate for transportation
				  services and related expenses are:
A.
				private automobile use is reimbursed by the mile, based on the established MAD
				reimbursement schedule;
B. meals
				are reimbursed at the rate established by MAD; authorization forms used for
				direct payment to medicaid meal providers by MAD are available through the
				recipient's local county ISD office;
C. lodging is reimbursed at the rate
				established by MAD; authorization forms for direct payment to medicaid lodging
				providers by MAD are available through the recipient's local county ISD office;
				and
D. the CMT fund reimbursement
				rate for transportation services is at the established MAD reimbursement
				schedule per mile when a private automobile is used.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 302 - MEDICAID GENERAL PROVIDER POLICIES › Part 1 - GENERAL PROVIDER POLICIES › Section 8.302.1.3 - 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 state statute.
				  See 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 302 - MEDICAID GENERAL PROVIDER POLICIES › Part 1 - GENERAL PROVIDER POLICIES › Section 8.302.1.5 - EFFECTIVE DATE

Current through Register Vol. 35, No. 13, July 16, 2024
July 1, 2024, unless a late date is cited at the end of a
				  section.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 302 - MEDICAID GENERAL PROVIDER POLICIES › Part 1 - GENERAL PROVIDER POLICIES › Section 8.302.1.6 - OBJECTIVE

Current through Register Vol. 35, No. 13, July 16, 2024
The objective of these rules is to provide instructions for
				  the service portion of the New Mexico medical assistance
				  programs.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 302 - MEDICAID GENERAL PROVIDER POLICIES › Part 1 - GENERAL PROVIDER POLICIES › Section 8.302.1.7 - DEFINITIONS

Current through Register Vol. 35, No. 13, July 16, 2024
Medically necessary services
A. Medically necessary services are clinical
				and rehabilitative physical or behavioral health services that:
(1) are essential to prevent, diagnose or
				treat medical conditions or are essential to enable an eligible recipient to
				attain, maintain or regain functional capacity;
(2) are delivered in the amount, duration,
				scope and setting that is clinically appropriate to the specific physical and
				behavioral health care needs of the eligible recipient;
(3) are provided within professionally
				accepted standards of practice and national guidelines; and
(4) are required to meet the physical and
				behavioral health needs of the eligible recipient and are not primarily for the
				convenience of the eligible recipient, the provider or the payer.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 302 - MEDICAID GENERAL PROVIDER POLICIES › Part 1 - GENERAL PROVIDER POLICIES › Section 8.302.1.8 - 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 302 - MEDICAID GENERAL PROVIDER POLICIES › Part 1 - GENERAL PROVIDER POLICIES › Section 8.302.1.9 - GENERAL PROVIDER POLICIES

Current through Register Vol. 35, No. 13, July 16, 2024
Medically necessary services are reimbursed by the MAD under
				  Title XIX of the Social Security Act as amended, or by state
				  statute.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 302 - MEDICAID GENERAL PROVIDER POLICIES › Part 1 - GENERAL PROVIDER POLICIES › Section 8.302.1.10 - ELIGIBLE PROVIDERS

Current through Register Vol. 35, No. 13, July 16, 2024
A. Upon
				the approval of a New Mexico MAD provider participation agreement by MAD or its
				designee, a licensed practitioner or facility that meets applicable
				requirements is eligible to be reimbursed for furnishing covered services to an
				eligible program recipient. A provider must be enrolled before submitting a
				claim for payment to the appropriate MAD claims processing contractor. 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,
				billings instructions, utilization review instructions, and other pertinent
				materials. When enrolled, providers receive instructions on how to access these
				documents. It is the provider's responsibility to access these instructions or
				ask for paper copies to be provided, to understand the information provided and
				to comply with the requirements. The provider must contact HCA or its
				authorized agents to request hard copies of any program rules manuals, billing
				and utilization review instructions, and other pertinent materials and to
				obtain answers to questions on or not covered by these materials. To be
				eligible for reimbursement, a provider is bound by the provisions of the MAD
				provider participation agreement and all applicable statutes, regulations and
				executive orders.
B. When services
				are billed to and paid by a coordinated services contractor authorized by HCA,
				the provider must also enroll as a provider with the coordinated services
				contractor and follow that contractor's instructions for billing and for
				authorization of services.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 302 - MEDICAID GENERAL PROVIDER POLICIES › Part 1 - GENERAL PROVIDER POLICIES › Section 8.302.1.11 - PROVIDER RESPONSIBILITIES AND REQUIREMENTS

Current through Register Vol. 35, No. 13, July 16, 2024
A provider who furnishes services to a medicaid eligible
				  recipient agrees to comply with all federal and state laws, regulations, and
				  executive orders relevant to the provision of services. A provider also must
				  conform to MAD program rules, instructions, and 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. A provider must verify that individuals are
				  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.
A. Eligibility
				determination: A provider must verify recipient eligibility prior to providing
				services and verify that the recipient remains eligible throughout periods of
				continued or extended services.
(1) A provider
				may verify eligibility through several mechanisms, including using the
				automated voice response system, contacting MAD or designated contractor
				eligibility help desks, contracting with an eligibility verification system
				vendor, or by using the New Mexico medicaid portal.
(2) An eligible recipient becomes financially
				responsible for a provider claim if the eligible recipient:
(a) fails to identify themselves as a MAD
				eligible recipient; or
(b) fails to
				state that an eligibility determination is pending; or
(c) fails to furnish MAD identification
				before the service is rendered and MAD denies payment because of the resulting
				inability of the provider to be able to file a claim timely; or
(d) receives services from a provider that
				lacks MAD enrollment, is not eligible to provide the services or does not
				participate in MAD programs.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 302 - MEDICAID GENERAL PROVIDER POLICIES › Part 1 - GENERAL PROVIDER POLICIES › Section 8.302.1.12 - ELIGIBLE MEDICAID RECIPIENTS

Current through Register Vol. 35, No. 13, July 16, 2024
To comply with Title XIX of the Social Security Act, as
				  amended, MAD is required to serve certain groups of eligible recipients and has
				  the option of paying for services provided to other eligible recipient groups
				  42 CFR 435.1 . MAD is also required to pay for emergency services furnished to
				  non-citizens residing in New Mexico who are not lawfully admitted for permanent
				  residence but who otherwise meet the eligibility requirements. Coverage is
				  restricted to those services necessary to treat an emergency medical condition,
				  which includes labor and delivery services. See
				  8.325.10.3 NMAC.
A. Recipient eligibility determination: To be
				eligible to receive MAD benefits, an applicant/ recipient must meet general
				eligibility or resource and income requirements. These requirements vary by
				category of eligibility and may vary between health care programs. See 8.200
				NMAC for information on medicaid eligibility requirements.
(1) An otherwise eligible recipient who is
				under the jurisdiction or control of the correctional system or resides in a
				public institution is not eligible for medicaid.
(2) MAD eligibility determinations are made
				by the following agencies:
(a) the staff of
				the income support division (ISD) county offices determines eligibility for
				medicaid categories of eligibility;
(b) the staff of the New Mexico children,
				youth and families department (CYFD) determines eligibility for child
				protective services, adoptive services and foster care children;
(c) the staff of the social security
				administration determines eligibility for social security income (SSI);
				and
(d) the staff of a federally
				qualified health center, a maternal and child health services block grant
				program, the Indian health service, and other designated agents make
				presumptive eligibility determinations.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 302 - MEDICAID GENERAL PROVIDER POLICIES › Part 1 - GENERAL PROVIDER POLICIES › Section 8.302.1.13 - PATIENT SELF DETERMINATION ACT

Current through Register Vol. 35, No. 13, July 16, 2024
A hospital, nursing facility, intermediate care facility for
				  individuals with intellectual disabilities, hospice agency and home health
				  agency is required to give an eligible recipient or personal representative
				  information about their right to make their own health decisions, including the
				  right to accept or refuse medical treatment, pursuant to the Omnibus Budget
				  Reconciliation Act (OBRA) of 1990. An eligible recipient is not required by
				  this legislation to execute advance directives. Advance directives, such as
				  living wills or durable power of attorney documents, must be established in a
				  manner which is recognized under New Mexico state law. See applicable state
				  law. A health care provider cannot object on the basis of conscience when an
				  eligible recipient or personal representative wishes to implement an advance
				  directive.
A. Information
				requirements: At the time of admission, a provider is required to provide
				written information to an adult eligible recipient or personal representative
				concerning their right to do the following:
(1) make decisions about their medical
				care;
(2) accept or refuse medical
				or surgical treatment;
(3) execute
				advance directives;
(4) execute
				their rights under HIPAA; and
(5)
				if an eligible recipient who is already incapacitated is admitted, the provider
				must provide their personal representatives with this information; if an
				eligible recipient is no longer incapacitated, the provider must discuss these
				rights with the eligible recipient.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 302 - MEDICAID GENERAL PROVIDER POLICIES › Part 1 - GENERAL PROVIDER POLICIES › Section 8.302.1.14 - NONDISCRIMINATION

Current through Register Vol. 35, No. 13, July 16, 2024
A provider must furnish covered services to an eligible
				  recipient in the same scope, quality and manner as provided to the general
				  public. Within the limits of medical assistance programs, a provider may not
				  discriminate on the basis of race, color, national origin, sex, gender, age,
				  ethnicity, religion, sexual orientation, sexual preference, health status,
				  disability, marital status, political belief, or source of payment,
				  (45 CFR
				  80.3 (a)(b);
				  45 CFR
				  84.52 (a);
				  42 CFR
				  447.20; and
				  PL
				  101-366, 104 Stat. 327 (1990)).
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 302 - MEDICAID GENERAL PROVIDER POLICIES › Part 1 - GENERAL PROVIDER POLICIES › Section 8.302.1.15 - BILLING AND CLAIMS PROCESSING

Current through Register Vol. 35, No. 13, July 16, 2024
Reimbursement to a provider for services or procedures is
				  based on the MAD reimbursement fee schedule, reimbursement rate, or
				  reimbursement methodology in place at the time the services were furnished by
				  the provider. A provider who furnishes services to an eligible recipient agrees
				  to accept the amount paid by MAD as payment in full, except as otherwise
				  allowed by rule or regulation (42 CFR 447.15).
A. Requirements for reimbursement: A provider
				is reimbursed for performing a service or procedure only if any required prior
				authorization, documentation, certifications, or acknowledgements are submitted
				with the claim and the claim is received by the appropriate claims processing
				contractor within the filing limits.
B. Electronic billing requirements: Effective
				December 1, 2008, electronic billing of claims is mandatory unless an exemption
				has been allowed by MAD. Electronic billing improves the accuracy of claims
				submission and payment; provides consistency in billing information; and
				improves the speed of payment. Exemptions will be given on a case by case basis
				with consideration given to barriers the provider may face in billing
				electronically, including when volumes are so small that developing electronic
				submission capability is impractical. The requirement for electronic submission
				of claims does not apply to situations for which paper attachments must
				accompany the claim form.
C.
				Responsibility for claims: A provider is responsible for all claims submitted
				under their national provider identifier (NPI) or other provider number
				including responsibility for accurate coding that represents the services
				provided without inappropriately upcoding, unbundling, or billing mutually
				exclusive codes as indicated by published coding manuals, directives, and the
				CMS correct coding initiative.
D.
				No billing of recipients or third parties: With the exception of WDI and SCHIP
				or other specified program co-payments or cost-sharing, a provider may not
				bill, turn over to collection, or accept payment from an eligible recipient,
				their personal representative or other third parties determined to be legally
				responsible for the balance of a claim except as specifically allowed by MAD
				regulations. Following MAD payment, a provider cannot seek additional payment
				from an eligible recipient or their personal representative in addition to the
				amount paid by MAD. Following MAD denial of payment due to provider
				administrative error in filing a claim, a provider cannot seek payment from an
				eligible recipient or their personal representative or turn the balance over to
				collection. See 8.302.3 NMAC,
Third Party Liability Provider
				Responsibilities
.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 302 - MEDICAID GENERAL PROVIDER POLICIES › Part 1 - GENERAL PROVIDER POLICIES › Section 8.302.1.16 - ACCEPTANCE OF RECIPIENT OR THIRD PARTY PAYMENTS

Current through Register Vol. 35, No. 13, July 16, 2024
A provider may only bill an eligible recipient or accept
				  payment for services if all of the following requirements are satisfied:
A. The eligible recipient is advised by the
				provider before services are furnished that a particular service is not covered
				by MAD or that the particular provider does not accept patients whose medical
				services are paid for by MAD.
B.
				The eligible recipient is provided with information by the provider regarding
				the necessity, options, and charges for the service, and of the option of going
				to a provider who accepts MAD payment.
C. The eligible recipient still agrees in
				writing to have specific services provided with the knowledge that he will be
				financially responsible for payment.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 302 - MEDICAID GENERAL PROVIDER POLICIES › Part 1 - GENERAL PROVIDER POLICIES › Section 8.302.1.17 - RECORD KEEPINGAND DOCUMENTATION REQUIREMENTS

Current through Register Vol. 35, No. 13, July 16, 2024
A provider must maintain all the records necessary to fully
				  disclose the nature, quality, amount and medical necessity of services
				  furnished to an eligible recipient who is currently receiving or who has
				  received services in the past. (42 CFR
				  431.107(b)). Services billed
				  to MAD not substantiated in the eligible recipient's records are subject to
				  recoupment. Failure to maintain records for the required time period is a
				  violation of the Medicaid Provider Act, Section 27-11-1, et. seq. NMSA 1978,
				  and a crime punishable under the Medicaid Fraud Act, Section 30.44-5 NMSA 1978.
				  See 8.351.2 NMAC,
Sanctions and Remedies
.
A. Detail required in records: Provider
				records must be sufficiently detailed to substantiate the date, time, eligible
				recipient name, rendering, attending, ordering or prescribing provider; level
				and quantity of services; length of a session of service billed, diagnosis and
				medical necessity of any service.
(1) When
				codes, such as the international classification of disease (ICD) or current
				procedural terminology (CPT), are used as the basis for reimbursement, provider
				records must be sufficiently detailed to substantiate the codes used on the
				claim form.
(2) Treatment plans or
				other plans of care must be sufficiently detailed to substantiate the level of
				need, supervision, and direction and service(s) needed by the eligible
				recipient.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 302 - MEDICAID GENERAL PROVIDER POLICIES › Part 1 - GENERAL PROVIDER POLICIES › Section 8.302.1.18 - PATIENT CONFIDENTIALITY

Current through Register Vol. 35, No. 13, July 16, 2024
A provider is required to comply with the HIPAA privacy
				  regulations. Confidential medical information regarding medicaid information on
				  the applicant or eligible recipient must be released by providers to MAD, and
				  to other state or federal agencies, or their employees at no cost when:
A. the agency is involved in the
				administration of medicaid;
B. the
				information is to be used to establish eligibility, determine the amount of
				assistance or provide services related to medicaid;
C. the agency is subject to the same
				standards of confidentiality as MAD; and
D. the agency has the actual consent of
				applicant or eligible recipient or their personal representative for release of
				the information, or consent is obtained when an eligible recipient or their
				personal representative or a member of the assistance group makes application
				for benefits or services with the HCA.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 302 - MEDICAID GENERAL PROVIDER POLICIES › Part 1 - GENERAL PROVIDER POLICIES › Section 8.302.1.19 - PROVIDER DISCLOSURE

Current through Register Vol. 35, No. 13, July 16, 2024
A provider must furnish MAD with the following information.
				  See 42 CFR
				  431.107(b) (2)(3): name and
				  address of each person with an ownership or controlling interest in the entity
				  or in any subcontractor in which the entity has a direct or indirect ownership
				  interest totaling five percent or more, and any relationship (spouse, child or
				  sibling) of these persons to another; name of any other entity in which a
				  person with an ownership or controlling interest in the disclosing entity also
				  has an ownership or controlling interest; name of any person with an ownership
				  or controlling interest in the entity who has been convicted of a criminal
				  offense related to that person's involvement in any program established under
				  the medicare or medical assistance programs; and name of any provider who
				  employs or uses the services of an individual who, at any time during the year
				  preceding this employment, was employed in a managerial, accounting, auditing
				  or similar capacity, by an agency or organization which currently serves or at
				  any time during the preceding year served as a medicare or MAD fiscal
				  intermediary or carrier for the provider. A provider must notify MAD of any
				  change in the status of these disclosure provisions.
A. Reports furnished by providers: A provider
				must give MAD, the appropriate MAD claims processing contractor, MAD audit
				contractor, MAD utilization review contractor or MAD designated representative
				financial reports, audits, certified cost statements, medical and other
				records, or any other data needed to establish a basis for reimbursement at no
				cost.
(1) All information regarding any claim
				for services must be provided. See
				42 CFR
				431.107(b) (2).
(2) Required cost statements must be
				furnished no later than 150 calendar days of the close of the provider's fiscal
				accounting period.
(3) MAD records
				and other documentation needed by MAD or its designee must be available within
				a defined period, upon request.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 302 - MEDICAID GENERAL PROVIDER POLICIES › Part 1 - GENERAL PROVIDER POLICIES › Section 8.302.1.20 - TERMINATION OF PROVIDER STATUS

Current through Register Vol. 35, No. 13, July 16, 2024
A.
				Provider status may be terminated if the provider or MAD gives the other
				written notice of termination at least 60 calendar days before the effective
				termination date.
(1) Facility provider must
				also give at least 15 calendar days notice to the public by publishing a
				statement of the date services are no longer available at the facility in one
				or more newspapers of general circulation within the affected county or
				region.
(2) Normal termination and
				notice limits do not apply if the state survey agency or health care financing
				administration determines that the health and safety of residents in a nursing
				facility or intermediate care facility for the intellectually disabled or the
				children, youth and families department determines that the health and safety
				of children or adolescents in a residential treatment center, group home, or
				treatment foster care are in jeopardy.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 302 - MEDICAID GENERAL PROVIDER POLICIES › Part 1 - GENERAL PROVIDER POLICIES › Section 8.302.1.21 - CHANGE IN OWNERSHIP

Current through Register Vol. 35, No. 13, July 16, 2024
As soon as possible, but at least 60 calendar days after a
				  change in ownership, MAD reserves the right to withhold payment on all pending
				  or current claims until any right MAD has to recoup portions or all of those
				  payments is determined. Payment will not be withheld if MAD received written
				  confirmation that the new owner or previous medical assistance program provider
				  agrees to be responsible for any potential overpayment.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 302 - MEDICAID GENERAL PROVIDER POLICIES › Part 1 - GENERAL PROVIDER POLICIES › Section 8.302.1.22 - PUBLIC DISCLOSURE OF SURVEY INFORMATION

Current through Register Vol. 35, No. 13, July 16, 2024
The findings of a MAD survey used to determine the ability of
				  facility provider to begin or continue as medicaid participating provider is
				  available to the public within 90 calendar days of completion.
A. Documents subject to disclosure: Documents
				subject to public disclosure include:
(1)
				current survey reports prepared by the survey agency;
(2) official agency notifications of findings
				based on these reports, including statements of deficiencies;
(3) pertinent parts of written statements
				furnished by providers to the survey agency related to these reports and
				findings, including any corrective action taken or planned; and
(4) information regarding the ownership of
				nursing facility. See 42 CFR
				455.104(a).
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 302 - MEDICAID GENERAL PROVIDER POLICIES › Part 2 - RECIPIENT POLICIES -GENERAL RECIPIENT REQUIREMENTS › Section 8.302.2.3 - 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 (HHS) under Title XIX of the Social
				  Security Act as amended or by state statute. See Section 27-1-12
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 302 - MEDICAID GENERAL PROVIDER POLICIES › Part 2 - RECIPIENT POLICIES -GENERAL RECIPIENT REQUIREMENTS › Section 8.302.2.5 - EFFECTIVE DATE

Current through Register Vol. 35, No. 13, July 16, 2024
October 1, 2017, unless a later date is cited at the end of a
				  section.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 302 - MEDICAID GENERAL PROVIDER POLICIES › Part 2 - RECIPIENT POLICIES -GENERAL RECIPIENT REQUIREMENTS › Section 8.302.2.6 - OBJECTIVE

Current through Register Vol. 35, No. 13, July 16, 2024
The objective of this rule is to provide instruction for the
				  service portion of the New Mexico medical assistance programs
				  (MAP).
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 302 - MEDICAID GENERAL PROVIDER POLICIES › Part 2 - RECIPIENT POLICIES -GENERAL RECIPIENT REQUIREMENTS › Section 8.302.2.7 - DEFINITIONS

Current through Register Vol. 35, No. 13, July 16, 2024
A.
"Authorized representative"
means the individual designated to
				represent and act on behalf of the eligible recipient or member's behalf. The
				member or authorized representative must provide formal documentation
				authorizing the named individual or individuals to access the identified case
				information for a specified purpose and time frame. An authorized
				representative may be an attorney representing a person or household, a person
				acting under the authority of a valid power of attorney, a guardian, or any
				other individual or individuals designated in writing by the eligible recipient
				or member.
B.
"Eligible
				recipient"
means an individual who has met a medical assistance program
				(MAP) category of eligibility and receives his or her medical assistance
				division (MAD) services through the fee-for-service (FFS) program.
C.
"Member"
means a MAP eligible
				recipient and who receives his or her MAD services through a HSD contracted
				managed care organization (MCO).
D.
"Co-payment"
means a fixed dollar amount that a medicaid recipient
				must pay directly to a provider for a service, visit or item. A co-payment is
				to be charged at the time of service or receipt of the item.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 302 - MEDICAID GENERAL PROVIDER POLICIES › Part 2 - RECIPIENT POLICIES -GENERAL RECIPIENT REQUIREMENTS › Section 8.302.2.9 - BILLING FOR MEDICAID SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
Health care for New Mexico medical assistance program MAP
				  eligible recipients and members 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 (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 eligible recipients. A
				  provider must be enrolled before submitting a claim for payment to the MAD
				  claims processing contractors. 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 instruction, service standards,
				  utilization review (UR) 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 and to comply with the requirements. 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, service standards, UR instructions, and other pertinent material.
				  To be eligible for reimbursement, a provider must adhere to the provisions of
				  the MAD PPA and all applicable statutes, regulations, rules, billing
				  instructions, service standards, UR instructions, and executive orders. MAD or
				  its selected claims processing contractor issues payments to a provider using
				  electronic funds transfer (EFT) only. Providers must supply necessary
				  information in order for payment to be made. See 8.308.14 NMAC for additional
				  MCO provider responsibilities.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 302 - MEDICAID GENERAL PROVIDER POLICIES › Part 2 - RECIPIENT POLICIES -GENERAL RECIPIENT REQUIREMENTS › Section 8.302.2.10 - BILLING INFORMATION

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Billing for services:
MAD only makes payment to a provider or to
				the following individuals or organizations for services:
(1) a government agency or third party with a
				court order, based on a valid provider payment assignment; see 42 CFR Section
				447.10(d)(e); or
(2) a business
				agent, such as billing service or accounting firm that provides statements and
				receives payment in the name of the provider; the agent's compensation must be
				related to the cost of processing the claims and not based on a percentage of
				the amount that is billed or collected or dependent upon collection of the
				payment.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 302 - MEDICAID GENERAL PROVIDER POLICIES › Part 2 - RECIPIENT POLICIES -GENERAL RECIPIENT REQUIREMENTS › Section 8.302.2.13 - BILLING FOR CONTRACTED SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
MAD only makes payment to a provider who actually rendered
				  the services. However, in the following instances a MAD provider can bill and
				  be paid for covered contracted services.
A. A provider is reimbursed at encounter
				rates or other all-inclusive rates that may have some contracted services built
				into those rates. These providers include NF, ICF-IDD, residential treatment
				centers, a group home, a hospice agency, a federally qualified health center, a
				rural health clinic, and an IHS or tribal 638 facility.
B. A practitioner group, a clinic, an
				institutional professional component, and providers of professional services
				may bill for services furnished by practitioners under contract when the
				provider applications are approved by MAD, and the following apply:
(1) the MAD provider participation
				applications are completed by the billing entity and the practitioner rendering
				the service or in their employ; and
(2) the practitioner is listed as the
				rendering provider on the claim form.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 302 - MEDICAID GENERAL PROVIDER POLICIES › Part 2 - RECIPIENT POLICIES -GENERAL RECIPIENT REQUIREMENTS › Section 8.302.2.14 - BILLING AND PAYMENT LIMITATIONS

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Payment not allowed:
MAD does not pay factors either directly or
				by power of attorney
				42 CFR Section
				447.10(h). A factor is an
				individual or an organization, such as a collection agency or service
				bureau.
B.
No reimbursement
				for the discharge day:
An institutional or other residential provider,
				such as a NF, a hospital, an ICF-IID, and a provider of treatment foster care
				services are reimbursed for services furnished to an eligible recipient or
				member on the day of admission but are not reimbursed for services furnished on
				day of discharge.
C.
No
				payment made for wrong services:
A provider shall not bill MAD for:
(1) services provided to the wrong
				patient;
(2) a service performed on
				the wrong body part of an eligible recipient or member; and
(3) an incorrect procedure performed on an
				eligible recipient or member.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 302 - MEDICAID GENERAL PROVIDER POLICIES › Part 2 - RECIPIENT POLICIES -GENERAL RECIPIENT REQUIREMENTS › Section 8.302.2.15 - INTEREST RATES ON COST SETTLEMENTS

Current through Register Vol. 35, No. 13, July 16, 2024
MAD charges interest on overpayments and pays interest on
				  underpayments as a result of year-end cost settlements, unless waived.
A.
Interest periods:
Interest
				accrues from the date of the final determination of costs or from a date
				required by a subsequent administrative reversal. Interest is charged on the
				overpayment balance or paid on the underpayment balance for each 30 calendar
				day period that payment is delayed.
(1) For
				purposes of this provision, a final determination is considered to occur when:
(a) MAD, the MAD selected claims processing
				contractor, or the MAD audit contractor makes a written demand for payment or a
				written determination of underpayment; or
(b) a cost report which was filed in a timely
				manner indicates that an amount is due MAD and the amount due is not included
				with the report.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 302 - MEDICAID GENERAL PROVIDER POLICIES › Part 3 - RECIPIENT POLICIES -GENERAL RECIPIENT REQUIREMENTS › Section 8.302.3.3 - 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 Title XIX of the Social Security
				  Act, as amended and 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 302 - MEDICAID GENERAL PROVIDER POLICIES › Part 3 - RECIPIENT POLICIES -GENERAL RECIPIENT REQUIREMENTS › Section 8.302.3.5 - EFFECTIVE DATE

Current through Register Vol. 35, No. 13, July 16, 2024
May 1, 2018 unless a later date is cited at the end of a
				  section.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 302 - MEDICAID GENERAL PROVIDER POLICIES › Part 3 - RECIPIENT POLICIES -GENERAL RECIPIENT REQUIREMENTS › Section 8.302.3.6 - 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 medicaid programs.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 302 - MEDICAID GENERAL PROVIDER POLICIES › Part 3 - RECIPIENT POLICIES -GENERAL RECIPIENT REQUIREMENTS › Section 8.302.3.9 - THIRD PARTY LIABILITY PROVIDER RESPONSIBILITIES

Current through Register Vol. 35, No. 13, July 16, 2024
The New Mexico medical assistance program (medicaid) is the
				  payer of last resort. When resources are available from third parties, HSD
				  administers a specific program to ensure that these resources are used to pay
				  for the medical services furnished to eligible recipients. See 42 CFR Section
				  433 Subpart D - Third Party Liability and Subsection A of Section
				  27-2-23
				  NMSA 1978. This part provides an overview of this program, the collection
				  process, and the responsibilities of providers, insurers, and the department.
				  These provisions apply to the medical assistance program payments and to
				  payments made on behalf of members by HSD contracted medicaid managed care
				  organizations (MCOs).
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 302 - MEDICAID GENERAL PROVIDER POLICIES › Part 3 - RECIPIENT POLICIES -GENERAL RECIPIENT REQUIREMENTS › Section 8.302.3.10 - PAYMENT PROVISIONS

Current through Register Vol. 35, No. 13, July 16, 2024
For claims for recipients with medical coverage furnished by
				  a third party, such as an insurer or other third party who may be liable for
				  the medical bill, medicaid limits payment for the claim to the medicaid allowed
				  amount less the third party payment amount, not to exceed the co-payment,
				  co-insurance, deductible or other patient responsibility amount calculated by
				  the third party when the reimbursement methodology is similar to the
				  methodology used to calculate a medicaid payment, as determined by medical
				  assistance division (MAD). If the third party payment amount exceeds the
				  medicaid allowed amount, the medicaid program makes no further payment. The
				  claim is considered paid in full. The provider may not collect any remaining
				  portion of the unpaid co-payment, co-insurance, or deductible from the client.
				  If a hospital is reimbursed under the diagnostic related group (DRG)
				  reimbursement methodology and receives payments from third party insurers,
				  medicaid pays the hospital the difference between the amount received from the
				  third party and the lower of the hospital billed amount or the medicaid allowed
				  DRG amount.
A.
Payment
				acceptance:
When providers furnish medical services to eligible
				recipients who have health coverage or coverage from liable third parties,
				providers must not seek payment from the recipient.
B.
Sanctions for seeking recipient
				payments:
Sanctions are imposed if providers seek payment for services
				from recipients after receiving payments for these services from the eligible
				recipient's health insurance company or other third parties. An amount equal to
				three times the amount sought from eligible recipients is deducted from
				providers' next medicaid payment. See
				42 CFR Section
				447.21.
C.
Refunds to MAD after receipt of
				payment:
A provider must immediately refund the lower of the third party
				or medicaid payment, if he or she receives payment from insurance companies or
				health plans for services already paid for by medicaid.
D.
Provider discounts:
MAD does
				not pay the difference between the payment received from the third party, based
				on the discount agreement and the actual charges for services, when providers
				enter into agreements with third party payers to accept payment at less than
				actual charges.
(1) The provider acceptance of
				less than actual charges constitutes receipt of a full payment for services and
				neither medicaid nor eligible recipients have a further legal obligation for
				payment.
(2) Provider discount
				arrangements are often referred to as "preferred provider agreements" or
				"preferred patient care agreements".
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 302 - MEDICAID GENERAL PROVIDER POLICIES › Part 3 - RECIPIENT POLICIES -GENERAL RECIPIENT REQUIREMENTS › Section 8.302.3.11 - SUBROGATION RIGHTS

Current through Register Vol. 35, No. 13, July 16, 2024
When MAD makes payments on behalf of eligible recipients, HSD
				  is subrogated to the eligible recipient's right against a third party for
				  recovery of medical expenses to the extent of the payment. See Subsection B of
				  Section
				  27-2-23
				  NMSA 1978 (Repl. Pamp. 1991). If the eligible recipient is enrolled in the
				  medicaid managed care program, the extent of the payment is the amount actually
				  expended on the provision of care as documented by encounter data and not the
				  capitation amount paid by MAD to the medicaid managed care contractor. All
				  referrals indicating the existence of a third party medical resource are
				  verified by MAD or its contractors. After verification, indicators are placed
				  in the MAD claims processing contractor's eligibility file for use in claims
				  processing.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 302 - MEDICAID GENERAL PROVIDER POLICIES › Part 3 - RECIPIENT POLICIES -GENERAL RECIPIENT REQUIREMENTS › Section 8.302.3.13 - INSURANCE COVERAGE AND HEALTH MAINTENANCE ORGANIZATIONS AND OTHER INSURANCE PLANS

Current through Register Vol. 35, No. 13, July 16, 2024
Providers must not refuse to furnish services to eligible
				  recipients solely because an insurance company or third party may be liable for
				  payment. See
				  42 CFR Section
				  447.20(b). When providers
				  are aware of the existence of health insurance or health plan coverage for
				  eligible recipients, the providers must seek payment from the insurance carrier
				  before seeking payment from medicaid. Providers who do not participate in a
				  specific health maintenance organization (HMO) or managed care plan (plan) are
				  not required to furnish services to an eligible recipient who has primary
				  coverage with such HMO or plan. The provider should refer the eligible
				  recipient to a provider who participates in the eligible recipient's HMO or
				  plan.
A.
Eligible recipients
				with insurance coverage through a HMO or other insurance plan:
When a
				medicaid eligible recipient belongs to a HMO or other insurance plan, the
				medicaid program limits the medicaid allowed amount less the third party
				payment amount, not to exceed the co-payment, deductible, co-insurance, and
				other patient responsibility amounts calculated by the HMO or other insurance
				plan. If the third party payment amount exceeds the medicaid allowed amount,
				the medicaid program makes no further payment and the claim is considered paid
				in full. The provider may not collect any portion of the unpaid co-payment,
				co-insurance, or deductible, or other patient responsibility from the eligible
				recipient. All other HMO requirements, including servicing provider
				restrictions, apply to the provision of services.
B. Eligible recipients covered by a HMO or
				other insurance plan are responsible for payment for medical services obtained
				outside the other plan without complying with the rules or policies of the HMO
				or other insurance plan.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 302 - MEDICAID GENERAL PROVIDER POLICIES › Part 3 - RECIPIENT POLICIES -GENERAL RECIPIENT REQUIREMENTS › Section 8.302.3.14 - PROVIDER LIENS ON PERSONAL INJURY AWARDS

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Hospital liens:
Hospitals are
				prohibited from imposing liens on potential lawsuit recoveries for the
				difference between the MAD payment and hospital billed amounts. MAD payment
				amounts are payment in full.
(1) Hospitals
				furnishing services to eligible recipients who have been injured in accidents
				may choose to file claims with MAD or forego medicaid reimbursement and file
				hospital liens against any potential lawsuit recoveries.
(2) If hospitals choose to bill medicaid,
				they must file claims within 120 calendar days of the date of
				discharge.
(3) If hospitals choose
				to impose a lien, they cannot bill eligible recipients or medicaid for any
				unpaid balance remaining after future settlement or lack of
				settlement.
(4) If hospitals file
				claims with MAD, the amounts received are payment in full.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 302 - MEDICAID GENERAL PROVIDER POLICIES › Part 3 - RECIPIENT POLICIES -GENERAL RECIPIENT REQUIREMENTS › Section 8.302.3.15 - NOTIFICATION REQUIREMENTS

Current through Register Vol. 35, No. 13, July 16, 2024
Providers must notify MAD or its appropriate contractor any
				  time they are contacted by an attorney or another interested party who requests
				  information relating to services furnished to eligible recipients, including
				  information on amounts billed or paid, procedures performed or medical records.
				  If an inquiry is received, providers must report to MAD or its appropriate
				  contractor the name and address of the party requesting the information; the
				  name and identification number of the eligible recipient and dates on which
				  services were furnished.