New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 314 - LONG TERM CARE SERVICES - WAIVERS › Part 5 - DEVELOPMENTAL DISABILITIES HOME AND COMMUNITY-BASED SERVICES WAIVER › Section 8.314.5.18 - PRIOR AUTHORIZATION AND UTILIZATION REVIEW

Current through Register Vol. 35, No. 13, July 16, 2024
All MAD services, including services covered under the DDW,
				  are subject to utilization review for medical necessity and program compliance.
				  Reviews may be performed before services are furnished, after services are
				  furnished and before payment is made, or after payment is made; see 8.310.2
				  NMAC. Once enrolled, providers receive instructions and documentation forms
				  necessary for prior authorization and claims processing.
A.
MAD prior authorization:
To
				be eligible for DDW services, a MAD eligible recipient must require the level
				of care (LOC) of services provided in an ICF-IID. LOC determinations are made
				by MAD or its designee. The eligible recipient's person centered ISP must
				specify the type, amount and duration of services and meet clinical criteria.
				Certain procedures and services specified in the ISP may require prior
				authorization from MAD or its designee. Services for which prior authorization
				was obtained remain subject to utilization review at any point in the payment
				process.
B.
DOH prior
				authorization:
Certain services are subject to utilization review by
				DOH.
C.
Eligibility
				determination:
Prior authorization of services does not guarantee that
				individuals are eligible for MAD services. Providers must verify that
				individuals are eligible for MAD services, including DDW services or other
				health insurance prior to the time services are furnished. An eligible
				recipient may not be institutionalized, hospitalized, or receive personal care
				option (PCO) services or other HCBS waiver services at the time DDW services
				are provided, except for certain case management services that are required to
				coordinate discharge plans or transition of services to DDW services.
D.
Third party assessor review
				process:
All services for DDW recipients will be reviewed by the TPA
				contracted by MAD. The TPA will adhere to deadlines set forth in its contract
				with the MAD. The TPA will make a clinical determination on whether the
				requested services and service amounts are needed, and will recommend whether
				the requested annual budget and ISP should be approved. If the TPA approves in
				whole or part the requested ISP and budget, the TPA will enter the approved
				portion of the budget into the medicaid management information system and issue
				a prior authorization to the case manager. If there is a denial in part or
				whole, the TPA decision must be in writing, identify a list of all documents
				and input considered by the TPA team during its review, and state the reasons
				for any denial of requested services. The eligible recipient, case manager, and
				guardian (if applicable) will be provided with this written determination and
				notice of an opportunity to request a fair hearing as well as an agency review
				conference.
(1) The eligible recipient, case
				manager, and guardian (if applicable) may submit to the TPA additional
				information relating to support needs.
(2) The decision of the TPA approving
				services requested by the DDW participant is binding on the State. However, the
				state may agree to overturn a decision to deny services requested by the DDW
				participant at a requested agency conference.