reglab/statecodes huggingface dataset:
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 325 - SPECIALTY SERVICES › Part 4 - HOSPICE CARE SERVICES › Section 8.325.4.14 - PRIOR AUTHORIZATION AND UTILIZATION REVIEW

Current through Register Vol. 35, No. 13, July 16, 2024
Hospice services are subject to utilization review for
				  medical necessity and program compliance. These reviews can be performed before
				  services are furnished, after services are furnished and before payment is
				  made, after payment is made, or at any point in the service or payment process.
				  See 8.302.5 NMAC,
Prior Authorization and Utilization Review
.
				  Once enrolled, providers receive utilization review instructions and
				  documentation forms which assists in the receipt of prior authorization and
				  claims processing.
A. Prior
				authorization: Hospice services do not require prior authorization. Services
				remain subject to review at any point in the payment process for medical
				necessity.
B. Eligibility
				determination: Prior authorization 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 are
				dissatisfied with a utilization review decision or action can request a
				re-review and a reconsideration. See 8.350.2 NMAC,
Reconsideration of
				Utilization Review Decisions
.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 325 - SPECIALTY SERVICES › Part 4 - HOSPICE CARE SERVICES › Section 8.325.4.15 - NONCOVERED SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
Hospice services are subject to the limitations and coverage
				  restrictions that exist for other medicaid services. See 8.301.3 NMAC,
General Noncovered Services
. Medicaid does not cover the
				  following hospice services.
A. Core
				services furnished by nonemployees. Core services when furnished routinely by
				non-employees or contracted staff are not covered by medicaid. A hospice can
				bill only for contracted staff necessary to supplement hospice employees in
				meeting recipient needs during periods of peak patient loads.
B. Bereavement counseling furnished to
				families after a recipient's death is a required hospice service, however,
				hospice agencies are not paid an additional amount for furnishing these
				services.
C. Inpatient respite care
				for more than five consecutive days. After five days, additional inpatient
				respite care is reimbursed as routine home care. Respite care cannot be
				furnished if the recipient lives in a long-term care facility.
D. Hospice services furnished by
				nondesignated hospices are not a covered benefit.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 325 - SPECIALTY SERVICES › Part 4 - HOSPICE CARE SERVICES › Section 8.325.4.16 - PATIENT SELF DETERMINATION ACT

Current through Register Vol. 35, No. 13, July 16, 2024
All adult recipients must be informed of their right to make
				  health decisions, including the right to accept or refuse medical treatment, as
				  specified in the Patient Self-Determination Act. See 8.302.1 NMAC,
General Provider Policies
.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 325 - SPECIALTY SERVICES › Part 4 - HOSPICE CARE SERVICES › Section 8.325.4.17 - REIMBURSEMENT

Current through Register Vol. 35, No. 13, July 16, 2024
Hospice providers must submit claims for reimbursement on the
				  UB-92 claim form or its successor. Election documentation must be submitted
				  with the initial claim. See 8.302.2 NMAC,
Billing for Medicaid
				  Services
. Once enrolled, providers receive instructions on
				  documentation, billing and claims processing. Medicaid reimbursement for
				  hospice care is made at one of four prospective daily rates, depending on the
				  level of care furnished.
The only retroactive adjustment to reimbursement is the
				  year-end application of the limitation on inpatient care payment. Physician
				  services are reimbursed separately from the hospice daily rate.
A. Payment for hospice care:
(1) Payment rates for hospice care services
				are determined by the centers for medicare and medicaid services (CMS), with
				local adjustments for wage differences within each category. Reimbursement for
				hospice services is based on one of four all-inclusive daily rate categories.
				The daily rate for each category includes all services necessary for palliative
				care, such as the purchase of needed medications, durable medical equipment,
				and medical supplies. The following are basic categories of hospice care:
(a) "routine home care day" defined as a day
				on which the recipient receives hospice care at home that is not defined as
				continuous care;
(b) "continuous
				home care day" defined as a day on which the recipient is not in an inpatient
				facility and receives nursing services for eight consecutive hours in a 24 hour
				period; this care is furnished only during brief periods of crisis to maintain
				the recipient at home; home health aide or homemaker services can also be
				furnished on a continuous basis, but these services are considered routine
				care;
(c) "inpatient respite care
				day" defined as a day on which a recipient receives care in approved facilities
				on a short-term basis to provider respite for the recipient's family or primary
				caregiver; and
(d) "general
				inpatient care day" defined as a day on which a recipient receives care in
				inpatient facilities for pain control or acute or chronic symptom management
				that cannot be managed in other settings.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 325 - SPECIALTY SERVICES › Part 4 - HOSPICE CARE SERVICES › Section 8.325.4.18 - HOSPICE SERVICES FOR RECIPIENTS IN NURSING FACILITIES

Current through Register Vol. 35, No. 13, July 16, 2024
If a recipient does not have family or friends to provide the
				  necessary care to allow the recipient to remain at home (home does not include
				  an adult foster care setting or a home for the aged), a recipient living in a
				  nursing facility (NF) can elect to receive hospice care. The NF is considered
				  the recipient's place of residence. The NF and the designated hospice must sign
				  a cooperative agreement that the hospice is responsible for the professional
				  management of the recipient's hospice care and the NF provides room and
				  board.
A. Room and board services: The
				agreement must specify that the NF provides the following room and board
				services:
(1) perform personal care
				services;
(2) help with activities
				of daily living;
(3) provide
				socializing activities;
(4)
				administer medication;
(5) maintain
				room cleanliness; and
(6) supervise
				the use of durable medical equipment and prescribed therapies.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 325 - SPECIALTY SERVICES › Part 8 - REHABILITATION SERVICE PROVIDERS › Section 8.325.8.3 - 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 325 - SPECIALTY SERVICES › Part 8 - REHABILITATION SERVICE PROVIDERS › Section 8.325.8.6 - 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 325 - SPECIALTY SERVICES › Part 8 - REHABILITATION SERVICE PROVIDERS › Section 8.325.8.8 - 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 325 - SPECIALTY SERVICES › Part 8 - REHABILITATION SERVICE PROVIDERS › Section 8.325.8.9 - REHABILITATION SERVICE PROVIDERS

Current through Register Vol. 35, No. 13, July 16, 2024
Rehabilitation services are optional services covered for New
				  Mexico medicaid program (medicaid) recipients [
				  42
				  CFR Section 440.110 ]. This part describes
				  eligible providers, covered services, service limitations, and general
				  reimbursement methodology.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 325 - SPECIALTY SERVICES › Part 8 - REHABILITATION SERVICE PROVIDERS › Section 8.325.8.10 - 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
				providers are eligible to be reimbursed for furnishing outpatient
				rehabilitation services to recipients:
(1)
				rehabilitation centers with a primary emphasis on physical therapy,
				occupational therapy or speech therapy which are licensed and certified by the
				public health division of the department of health. Alcohol or drug treatment
				centers are excluded;
(2) physical
				therapists licensed as physical therapists and certified in independent
				practice for participation in the medicare program by the public health
				division of the department of health;
(3) occupational therapists licensed as
				occupational therapists and certified in independent practice for participation
				in the medicare program by the public health division of the department of
				health;
(4) home health agencies
				licensed and certified by the public health division of the department of
				health; and
(5) general hospitals
				eligible to provide outpatient rehabilitation services licensed and certified
				by the public health division of the department of health.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 325 - SPECIALTY SERVICES › Part 8 - REHABILITATION SERVICE PROVIDERS › Section 8.325.8.11 - 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
.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 325 - SPECIALTY SERVICES › Part 8 - REHABILITATION SERVICE PROVIDERS › Section 8.325.8.12 - COVERED SERVICES AND SERVICE LIMITATIONS

Current through Register Vol. 35, No. 13, July 16, 2024
Medicaid covers physical therapy, occupational therapy, and
				  speech therapy services which are reasonable and necessary for the treatment of
				  the recipient's specific condition.
A.
				For all services, there must be an expectation that the recipient's condition
				will improve significantly in a reasonable and generally predictable period of
				time based on an assessment by physicians of the recipient's restoration
				potential.
(1) If the recipient's expected
				restoration potential is insignificant in relation to the extent and duration
				of therapy required to achieve the potential, the therapy is not considered
				reasonable and necessary.
(2) If a
				determination that the expectations for restoration will not materialize is
				made at any point in the treatment, the services are no longer covered by
				medicaid.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 325 - SPECIALTY SERVICES › Part 8 - REHABILITATION SERVICE PROVIDERS › Section 8.325.8.13 - NONCOVERED SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
Rehabilitation services are subject to the limitations and
				  coverage restrictions of other medicaid services. See 8.301.3 NMAC,
General Noncovered Services
. Medicaid does not cover the
				  following rehabilitation services:
A.
				services furnished by providers who are not licensed and/or certified to
				furnish services;
B. educational
				programs or vocational training not part of an active treatment plan for
				residents in an intermediate care facility for the mentally retarded or for
				recipients under the age of twenty-one (21) receiving inpatient psychiatric
				services [
				42 CFR Section
				441.13(b) ];
C. services billed separately by home health
				agencies, independent physical therapists, independent occupational therapists,
				or outpatient rehabilitation centers to recipients in high nursing facilities
				or inpatient hospitals;
D.
				transportation, for recipients in low level nursing facilities or other
				medicaid recipients, to travel to outpatient hospital facilities unless there
				are no home health agencies, independent physical therapists or independent
				occupational therapists available in the area to provide the therapy at the
				recipient's residence; and
E.
				services solely for maintenance of the recipient's general condition; these
				services include repetitive services needed to maintain a recipient's
				functional level that do not involve complex and sophisticated therapy
				procedures requiring the judgement and skill of a therapist; services related
				to activities for the general good and welfare of recipients, such as general
				exercises to promote overall fitness and flexibility and activities to provide
				general motivation, are not considered physical or occupational therapy for
				medicaid reimbursement purposes.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 325 - SPECIALTY SERVICES › Part 8 - REHABILITATION SERVICE PROVIDERS › Section 8.325.8.14 - 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:
All therapy services with the exception of the initial
				evaluation for physical or occupational therapy require prior approval for
				medical necessity 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 325 - SPECIALTY SERVICES › Part 8 - REHABILITATION SERVICE PROVIDERS › Section 8.325.8.15 - REIMBURSEMENT

Current through Register Vol. 35, No. 13, July 16, 2024
Outpatient rehabilitation providers must submit claims for
				  reimbursement on the HCFA-1500 or UB-92 claim form or their successor, as
				  appropriate for the provider. See 8.302.2 NMAC,
Billing for Medicaid
				  Services
. Once enrolled, providers receive instructions on
				  documentation, billing and claims processing.
A.
Reimbursement for outpatient
				hospital rehabilitation medical services:
For services reimbursed under
				the Title XVIII (medicare) allowable cost methodology, medicaid reduces the
				medicare allowable costs by three percent (3%). The interim rate of payment is
				seventy-seven percent (77%) of billed charges. Medicaid reimbursement does not
				exceed reasonable costs as defined by medicare. See 8.311.2 NMAC,
Hospital Services
.
B.
Reimbursement for home health agency
				rehabilitation:
See Section MAD-768,
Home Health
				Services.
C.
Reimbursement for independent physical therapists, independent
				occupational therapists and rehabilitation centers:
(1) Reimbursement to providers is made at the
				lesser of the following:
(a) the provider's
				billed charge; or
(b) the MAD fee
				schedule for the specific service or procedure.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 325 - SPECIALTY SERVICES › Part 9 - HOME HEALTH SERVICES › Section 8.325.9.3 - 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 Sections 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 325 - SPECIALTY SERVICES › Part 9 - HOME HEALTH SERVICES › Section 8.325.9.6 - 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 325 - SPECIALTY SERVICES › Part 9 - HOME HEALTH SERVICES › Section 8.325.9.8 - 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 325 - SPECIALTY SERVICES › Part 9 - HOME HEALTH SERVICES › Section 8.325.9.9 - HOME HEALTH SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
The New Mexico medicaid program (medicaid) pays for medically
				  necessary health services furnished to eligible recipients, including home
				  health services 42 CFR, Section 484 and
				  42 CFR, Section
				  440.70. This part describes eligible
				  providers, covered services, service limitations, and the general reimbursement
				  methodology.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 325 - SPECIALTY SERVICES › Part 9 - HOME HEALTH SERVICES › Section 8.325.9.10 - 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), home health
				agencies that meet the following conditions are eligible to be reimbursed for
				furnishing services:
(1) meet the conditions
				of participation. See 42 CFR, Section 484 Subpart B;
(2) are licensed and certified by the
				licensing and certification bureau of the HCA to meet all standards for
				participation in a federal program established under Title XVIII (medicare) of
				the Social Security Act. Any provider participating only in medicaid must be
				licensed and certified to comply with the standards for medicare participation;
				and
(3) are public agencies,
				private for-profit agencies, or private non-profit agencies primarily engaged
				in furnishing skilled nursing services and at least one other therapeutic
				service.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 325 - SPECIALTY SERVICES › Part 9 - HOME HEALTH SERVICES › Section 8.325.9.11 - PROVIDER RESPONSIBILITIES

Current through Register Vol. 35, No. 13, July 16, 2024
A.
				Providers who furnish services to medicaid recipients must comply with all
				specified medicaid participation requirements. See 8.302.1 NMAC,
General Provider Policies
.
B. 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. Providers shall have written policies
				concerning the acceptance of recipients and the feasibility of meeting the
				recipient's needs in the home care setting, which include, but are not limited
				to:
(1) an evaluation visit in the recipient's
				residence to consider the physical facilities available, capabilities and
				attitudes of the recipient, family members or significant others, the
				availability of care givers, if any, to help in the care of the patient, and
				the appropriateness of home health care for meeting the recipient's needs in a
				safe environment;
(2) the
				recipient's need to receive medical care at home;
(3) orders from the recipient's
				physician;
(4) documentation in the
				medical record of (1), (2) and (3). 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
.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 325 - SPECIALTY SERVICES › Part 9 - HOME HEALTH SERVICES › Section 8.325.9.12 - ELIGIBLE RECIPIENTS

Current through Register Vol. 35, No. 13, July 16, 2024
A.
				Recipients must have a medical need to receive care at home to be eligible for
				home health agency services and must be certified as such by their attending
				physicians. A medical need to receive care at home means that the recipient has
				a condition caused by illness or injury which renders him/her unable to leave
				the home to obtain necessary medical care and treatment (i.e., is essentially
				homebound) or that the medical need for care at home is more appropriate and
				cost-effective and will prevent or delay institutionalization. Recipients do
				not need to be bedridden to be considered as having a medical need to receive
				care at home. Recipients may be considered eligible to receive care at home if
				they meet one or more of the following criteria:
(1) recipients who cannot leave their
				residences without the use of wheelchairs, crutches, walkers or assistance from
				another individual;
(2) recipients
				who because of severe physical or mental illness or injury must comply with
				doctor's orders and avoid all stressful physical activity;
(3) recipients who cannot leave their
				residences because of danger caused by a mental condition;
(4) recipients who have just returned to
				their residence after hospital stays for severe illness or surgical procedures
				and whose activities are restricted by their physicians because of pain,
				suffering, medical limitation or danger of infection.;
(5) recipients who are at high risk during
				pregnancy, infancy or childhood and for whom home health care is more
				appropriate to their needs.
(6)
				recipients are not eligible to receive care at home just because they:
(a) cannot drive,
(b) have multiple medical problems
				or
(c) live in an isolated
				area.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 325 - SPECIALTY SERVICES › Part 9 - HOME HEALTH SERVICES › Section 8.325.9.13 - COVERED SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
A.
				Medicaid covers those home health services which are skilled, intermittent and
				medically necessary. The focus of home health services shall be on the
				curative, restorative or preventive aspects of care. The goal of these services
				shall be to assist the recipient to return to an optimum level of functioning
				and to facilitate the timely discharge of the recipient to self-care or to care
				by their family, guardian or significant other. Services must be ordered by the
				recipient's attending physician and included in the plan of care established by
				the recipient's attending physician in consultation with home health agency
				staff. The plan of care must be reviewed, signed and dated by the attending
				physician. The attending physician certifies that the recipient has a medical
				need to receive care at home at the initial certification, and as part of the
				plan of care review at recertification. The attending physician certifies that
				the recipient requires the skilled services of a nurse, physical therapist,
				occupational therapist or speech therapist. If the recipient requires home
				health aide services, the physician shall certify the need for these services.
				The evaluation visit is covered whether or not the recipient is admitted to
				home health care. Covered services include the following:
(1) skilled nursing services;
(2) home health aide services;
(3) physical and occupational therapy
				services; and
(4) speech therapy
				services.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 325 - SPECIALTY SERVICES › Part 9 - HOME HEALTH SERVICES › Section 8.325.9.14 - NONCOVERED SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
Home health services are subject to the limitations and
				  coverage restrictions of other medicaid services. See 8.301.3 NMAC,
General Noncovered Services
. Medicaid does not cover the
				  following home health agency services:
A. services beyond the initial evaluation
				which are furnished without prior approval;
B. home health services which are not
				skilled, intermittent and medically necessary;
C. services furnished to recipients who do
				not meet the eligibility criteria for home health services;
D. services furnished to recipients in places
				other than their place of residence;
E. services furnished to recipients who
				reside in intermediate care facilities for the mentally retarded or nursing
				facility (NF) residents who require a high NF level of service. Physical,
				occupational and speech therapy can be furnished to residents of nursing
				facilities who require a low level of service.
F. skilled nursing services which are not
				supervised by registered nurses; and
G. services not included in written plans of
				care established by physicians in consultation with the home health agency
				staff.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 325 - SPECIALTY SERVICES › Part 9 - HOME HEALTH SERVICES › Section 8.325.9.15 - PRIOR APPROVAL AND UTILIZATION REVIEW

Current through Register Vol. 35, No. 13, July 16, 2024
All medicaid services are subject to utilization review for
				  medical necessity and program compliance. Reviews 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 Approval and
				  Utilization Review
. Once enrolled, providers receive instructions and
				  documentation forms necessary for prior approval and claims processing.
A. Prior approval: All home health services
				beyond initial visits for evaluation purposes, 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. Prior approval does
				not guarantee payment, if upon utilization review after payment has occurred,
				recipients are determined to be ineligible or medical necessity is not
				found.
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 can request a re-review and a reconsideration. See 8.350.2
				NMAC,
Reconsideration of Utilization Review
				Decisions
.
D. Effect of
				hospitalization: If a recipient is hospitalized during the certification period
				and a significant change in condition or course of treatment occurs, the home
				health agency must treat the recipient as a new patient and submit a new prior
				approval request and new plan of care. If there is no significant change in the
				recipient's condition or course of treatment, an agency can resume care under
				the existing plan of care.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 325 - SPECIALTY SERVICES › Part 9 - HOME HEALTH SERVICES › Section 8.325.9.17 - REIMBURSEMENT

Current through Register Vol. 35, No. 13, July 16, 2024
Home health agencies assume responsibility for any and all
				  claims submitted on behalf of the provider and under the provider's number.
				  Home health agencies must submit claims for reimbursement on the UB-92 claim
				  form or its successor. See 8.302.2 NMAC,
Billing for Medicaid
				  Services
. Once enrolled, providers receive instructions on
				  documentation, billing and claims processing. Reimbursement is made based on
				  the Title XVIII (medicare) cost-finding procedures and reimbursement
				  methodology. Charges are paid at an interim rate basis established under the
				  medicaid guidelines by the medicare audit agent, subject to retroactive
				  settlement when the cost report is final. Cost reports on appropriate forms
				  must be submitted to the audit agent within 90 days of the close of the
				  provider's fiscal accounting period. Failure to provide timely cost reports
				  results in suspension of payments.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 325 - SPECIALTY SERVICES › Part 9 - HOME HEALTH SERVICES › Section 8.325.9.18 - REIMBURSEMENT LIMITATIONS

Current through Register Vol. 35, No. 13, July 16, 2024
The following limitations apply to reimbursement made to home
				  health agencies:
A. allowable costs
				are determined according to medicare and Title XIX (medicaid) reimbursement
				regulations;
B. the established
				percentage relationship of the agency's cost to charges per unity of services
				includes all services;
C.
				out-of-state providers are reimbursed at seventy percent of billed charges.
				Out-of-state home health services are approved only in very unusual
				circumstances, since home health services are furnished in the recipient's
				residence and that residence must be in New Mexico; and
D. claims for approved home health services
				must include the types of visits, dates of visits and number of
				visits.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 325 - SPECIALTY SERVICES › Part 9 - HOME HEALTH SERVICES › Section 8.325.9.19 - PLAN OF CARE

Current through Register Vol. 35, No. 13, July 16, 2024
A. The plan of
				care, established by the physician in consultation with the home health agency
				staff, and the request for prior approval must be received or postmarked within
				five working days of the proposed start of services or recertification period
				by MAD or its designee. Plans of care must be signed and dated by the
				physician, and prior approval must be received from MAD or its designee before
				claims are submitted to the MAD claims processing contractor. The plan of care
				must include the following:
(1) all principle
				diagnoses, surgical procedures, and other pertinent diagnoses;
(2) medications and dosages;
(3) types of services, equipment and
				non-routine supplies required;
(4)
				frequency of visits;
(5) safety
				measures to protect against injury;
(6) nutritional/ fluid balance
				requirements;
(7)
				allergies;
(8) functional
				limitations, activities permitted and documentation of homebound
				status;
(9) mental
				status;
(10) prognosis;
(11) goals and measurable objectives,
				including rehabilitation potential, long range projection of likely changes in
				the recipient's condition and plans for timely discharge to self-care or to
				care by family, guardian or significant other; and
(12) Clinical findings and updates.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 325 - SPECIALTY SERVICES › Part 10 - EMERGENCY MEDICAL SERVICES FOR NON-CITIZENS › Section 8.325.10.3 - STATUTORY AUTHORITY

Current through Register Vol. 35, No. 13, July 16, 2024
The New Mexico medicaid program and other health care
				  programs are administered pursuant to regulations promulgated by the federal
				  department of health and human services under the Social Security Act as
				  amended, or by state statute. See Section 27-2-12 et seq. NMSA 1978. Section
				  9-8-1 et seq. NMSA 1978 establishes the health care authority (HCA) as a
				  single, unified department to administer laws and exercise functions relating
				  to health care facility licensure and health care purchasing and
				  regulation.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 325 - SPECIALTY SERVICES › Part 10 - EMERGENCY MEDICAL SERVICES FOR NON-CITIZENS › Section 8.325.10.5 - EFFECTIVE DATE

Current through Register Vol. 35, No. 13, July 16, 2024
July 1, 2024, unless a later date is cited at the end of a
				  section.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 325 - SPECIALTY SERVICES › Part 10 - EMERGENCY MEDICAL SERVICES FOR NON-CITIZENS › Section 8.325.10.6 - 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 325 - SPECIALTY SERVICES › Part 10 - EMERGENCY MEDICAL SERVICES FOR NON-CITIZENS › Section 8.325.10.8 - MISSION STATEMENT

Current through Register Vol. 35, No. 13, July 16, 2024
To reduce the impact of poverty on people living in New
				  Mexico and to assure low income and individuals with disabilities in New Mexico
				  equal participation in the life of their communities.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 325 - SPECIALTY SERVICES › Part 10 - EMERGENCY MEDICAL SERVICES FOR NON-CITIZENS › Section 8.325.10.9 - EMERGENCY MEDICAL SERVICES FOR NON-CITIZENS

Current through Register Vol. 35, No. 13, July 16, 2024
The New Mexico MAD is required to pay for necessary emergency
				  medical services furnished to individuals who are non-citizens, reside in New
				  Mexico and meet the requirements for MAD eligibility
				  42 CFR
				  440.255(c).
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 325 - SPECIALTY SERVICES › Part 10 - EMERGENCY MEDICAL SERVICES FOR NON-CITIZENS › Section 8.325.10.10 - ELIGIBLE PROVIDERS

Current through Register Vol. 35, No. 13, July 16, 2024
Health care to eligible recipients is furnished by a variety
				  of providers and provider groups. The reimbursement and billing for these
				  services is administered by MAD. Upon approval of a New Mexico MAD provider
				  participation agreement by MAD or its designee, licensed practitioners,
				  facilities and other providers of services that meet applicable requirements
				  are eligible to be reimbursed for furnishing covered services to eligible
				  recipients. A provider must be enrolled before submitting a claim for payment
				  to the MAD claims processing contractors. MAD makes available on the HCA/MAD
				  website, on other program-specific websites, or in hard copy format,
				  information necessary to participate in health care programs administered by
				  HCA or its authorized agents, including program rules, billing instructions,
				  utilization review instructions, and other pertinent materials. When enrolled,
				  a provider receives instruction on how to access these documents. It is the
				  provider's responsibility to access these instructions, to understand the
				  information provided and to comply with the requirements. The provider must
				  contact HCA or its authorized agents obtain answers to questions related to the
				  material or not covered by the material. To be eligible for reimbursement, a
				  provider must adhere to the provisions of the MAD provider participation
				  agreement and all applicable statutes, regulations, and executive orders. MAD
				  or its selected claims processing contractor issues payments to a provider
				  using electronic funds transfer (EFT) only.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 325 - SPECIALTY SERVICES › Part 10 - EMERGENCY MEDICAL SERVICES FOR NON-CITIZENS › Section 8.325.10.11 - PROVIDER RESPONSIBILITIES

Current through Register Vol. 35, No. 13, July 16, 2024
A. A
				provider who furnishes services to a medicaid or other health care program
				eligible recipient must comply with all federal and state laws, regulations,
				and executive orders relevant to the provision of services as specified in the
				MAD provider participation agreement. A provider also must conform to MAD
				program rules and instructions as specified in the provider rules manual and
				its appendices, 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. When services are billed to and paid by a coordinated services
				contractor authorized by HCA, the provider must follow that contractor's
				instructions for billing and for authorization of services.
B. A provider may encourage an individual to
				apply for emergency medical services for non-citizens (EMSA) eligibility at a
				county office when the provider believes the service may qualify as an EMSA
				emergency service. A provider must inform the individual if the provider is
				unwilling to receive medicaid payment for the service when the service meets
				the EMSA emergency criteria for coverage. A provider must determine if the
				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
				a non-citizen recipient.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 325 - SPECIALTY SERVICES › Part 10 - EMERGENCY MEDICAL SERVICES FOR NON-CITIZENS › Section 8.325.10.12 - ELIGIBLE INDIVIDUALS

Current through Register Vol. 35, No. 13, July 16, 2024
A. An
				applicant must be a noncitizen who is undocumented or who does not meet the
				qualifying immigration criteria specified in 8.200.410 NMAC,
General
				Recipient Requirements,
and in 8.285.400 NMAC,
Medicaid
				Eligibility Emergency Medical Services for Non-Citizens-Category
				085.
B. Eligibility
				determinations are made by local county income support division (ISD) offices
				after the receipt of emergency services. The individual is responsible for
				completing an application at the local county ISD office and for providing all
				necessary documentation to prove that they meet the applicable eligibility
				criteria.
(1) An individual must apply for
				coverage at the ISD office no later than the last day of the third month
				following the month in which the alleged emergency services were
				received.
(2) A noncitizen
				recipient is responsible for notifying providers of the approval or denial of
				an application.
(3) If an
				application is denied or an application for coverage is not filed by the last
				day of the third month following the month in which the alleged emergency
				services were received, the non-citizen recipient is responsible for payment of
				the provider bill.
(4) If
				reimbursement for services is denied by MAD, the individual is responsible for
				payment and can be billed directly for payment by the provider.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 325 - SPECIALTY SERVICES › Part 10 - EMERGENCY MEDICAL SERVICES FOR NON-CITIZENS › Section 8.325.10.13 - COVERAGE CRITERIA

Current through Register Vol. 35, No. 13, July 16, 2024
A.
				"Emergency" as defined for EMSA includes labor and delivery including
				inductions and cesarean sections, as well as any other medical condition,
				manifesting itself with acute symptoms of sufficient severity such that the
				absence of immediate emergency medical attention could reasonably be expected
				to result in one of the following:
(1) the non
				citizen recipient's death;
(2)
				placement of the non-citizen recipient's health in serious jeopardy;
(3) serious impairment of bodily functions;
				or
(4) serious dysfunction of any
				bodily organ or part.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 325 - SPECIALTY SERVICES › Part 10 - EMERGENCY MEDICAL SERVICES FOR NON-CITIZENS › Section 8.325.10.14 - SERVICE LIMITATIONS

Current through Register Vol. 35, No. 13, July 16, 2024
To meet the categorical eligibility requirements, a recipient
				  who is a non-citizen must be a resident of the state of New Mexico. Proof of
				  residence must be furnished by the non-citizen to the local county ISD office.
				  An individual traveling through New Mexico, entering the United States through
				  New Mexico en route to another destination, visiting in New Mexico or touring
				  New Mexico with a tourist visa does not meet the residence
				  requirement.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 325 - SPECIALTY SERVICES › Part 10 - EMERGENCY MEDICAL SERVICES FOR NON-CITIZENS › Section 8.325.10.15 - NONCOVERED SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
MAD does not cover any medical service that is not necessary
				  to treat or evaluate a condition for an individual who is a non-citizen that
				  does not meet the definition of emergency. Additionally, MAD does not cover the
				  following specific services:
A. long
				term care;
B. organ
				transplants;
C. rehabilitation
				services;
D. elective surgical
				procedures;
E. psychiatric or
				psychological services;
F. durable
				medical equipment or supplies;
G.
				eyeglasses;
H. hearing
				aids;
I. outpatient
				prescriptions;
J. podiatry
				services;
K. prenatal and
				postpartum care;
L. well child
				care;
M. routine dental
				care;
N. routine dialysis
				services;
O. any medical service
				furnished by an out-of-state provider;
P. non-emergency transportation;
				and
Q. preventive care.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 325 - SPECIALTY SERVICES › Part 10 - EMERGENCY MEDICAL SERVICES FOR NON-CITIZENS › Section 8.325.10.16 - UTILIZATION REVIEW

Current through Register Vol. 35, No. 13, July 16, 2024
Claims for services to a recipient who is a non-citizen are
				  reviewed by MAD or its designee before payment to determine if the
				  circumstances warrant coverage.
A.
				Eligibility determination: A non-citizen recipient who requests MAD coverage
				for services must meet specific categorical eligibility requirements.
				Eligibility determinations by local county ISD offices must be made before the
				review for medical necessity.
B.
				Reconsideration: A provider and the non-citizen are given notice of the denial
				when the EMSA emergency criteria are not met. A non-citizen recipient can
				request a re-review and reconsideration of denied coverage of the service. See
				8.350.2 NMAC,
Reconsideration of Utilization Review Decisions
.
				A non-citizen recipient can also request a hearing. See 8.52.2 NMAC,
Recipient Hearings
.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 325 - SPECIALTY SERVICES › Part 10 - EMERGENCY MEDICAL SERVICES FOR NON-CITIZENS › Section 8.325.10.17 - REIMBURSEMENT

Current through Register Vol. 35, No. 13, July 16, 2024
Reimbursement is made according to the rules applicable to
				  the provider rendering the service.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 2 - CASE MANAGEMENT SERVICES FOR ADULTS WITH DEVELOPMENTAL DISABILITIES › Section 8.326.2.3 - 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 Sections 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 2 - CASE MANAGEMENT SERVICES FOR ADULTS WITH DEVELOPMENTAL DISABILITIES › Section 8.326.2.5 - EFFECTIVE DATE

Current through Register Vol. 35, No. 13, July 16, 2024
July 1, 2024, 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 2 - CASE MANAGEMENT SERVICES FOR ADULTS WITH DEVELOPMENTAL DISABILITIES › Section 8.326.2.6 - 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 2 - CASE MANAGEMENT SERVICES FOR ADULTS WITH DEVELOPMENTAL DISABILITIES › Section 8.326.2.8 - 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 2 - CASE MANAGEMENT SERVICES FOR ADULTS WITH DEVELOPMENTAL DISABILITIES › Section 8.326.2.9 - CASE MANAGEMENT SERVICES FOR ADULTS WITH DEVELOPMENTAL DISABILITIES

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
				  covered case management services furnished to adult recipients who have
				  developmental disabilities. This part describes eligible providers, eligible
				  recipients, covered services, service limitations and general reimbursement
				  methodology.