New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 324 - ADJUNCT SERVICES › Part 5 - VISION APPLIANCES, HEARING APPLIANCES, DURABLE MEDICAL EQUIPMENT, OXYGEN, MEDICAL SUPPLIES, PROSTHETICS AND ORTHOTICS › Section 8.324.5.13 - UTILIZATION REVIEW AND PRIOR AUTHORIZATION

Current through Register Vol. 35, No. 13, July 16, 2024
All MAD services are subject to UR 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. MAD makes available on its website and other websites
				  UR instructions. It is the provider's responsibility to access these
				  instructions or ask for hard copies to be provided, to understand the
				  information provided, to comply with the requirements, and to obtain answers to
				  questions not covered by these materials. Prior authorization does not
				  guarantee that an individual is eligible for a MAD service.
A.
Prior authorization:
Certain
				procedures or services may require prior authorization from MAD or its
				designee. Services for which prior authorization was obtained remain subject to
				UR at any point in the payment process. When services are billed to and paid by
				a coordinated services contractor authorized by MAD, the provider must follow
				that contractor's instructions for the authorization of a service. Written
				requests for items not included in the categories listed or for a quantity
				greater than that covered by MAD in this rule may be submitted by the MAP
				eligible recipient's PCP, with a prior authorization request to MAD or its
				designee for consideration of medical necessity.
B.
Eligibility determination:
The prior authorization of a service does not guarantee that an individual is
				eligible for a MAD service. A provider must verify that an individual is
				eligible for a specific MAD service at the time the service is furnished and
				must determine if the MAP eligible recipient has other health
				insurance.
C.
Reconsideration:
A provider who disagrees with a prior
				authorization denial or another review decision may request a reconsideration;
				see 8.350.2 NMAC.
D.
Prior
				authorization for specific services:
The following services and
				procedures require prior authorization from MAD or its designee:
(1) hearing appliances:
(a) hearing aid dispensing, purchase, rental
				and replacement;
(b) hearing aid
				repairs for which the provider's billed charge exceeds $100;
(c) services for which prior authorization
				was obtained remain subject to review at any point in the payment process;
				and
(d) medical clearance: PCP
				medical approval is required on any request for prior authorization for hearing
				aids; the MAP eligible recipient's PCP must certify that her or she is a
				suitable candidate for hearing aids by signing the hearing aid evaluation and
				information MAD prior authorization form; documentation must be on the PCP's
				letterhead or prescription pad; this documentation must be submitted with the
				prior approval request; a MAP eligible recipient under 16 years of age, must be
				examined by a physician who is board certified in the diagnosis and treatment
				of diseases and conditions of the ear for all hearing aid fittings.