New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 324 - ADJUNCT SERVICES › Part 4 - PHARMACY SERVICES, PRESCRIBING, AND PRACTITIONER ADMINISTERED DRUG ITEMS › Section 8.324.4.11 - PROVIDER RESPONSIBILITIES AND REQUIREMENTS

Current through Register Vol. 35, No. 13, July 16, 2024
A. A provider who furnishes services to an
				MAP eligible recipient must comply with all federal, state, local laws, rules,
				regulations, executive orders and the provisions of the provider participation
				agreement. A provider must adhere to MAD program rules as specified in the New
				Mexico administrative code (NMAC) and program policies that include but are not
				limited to supplements, billing instructions, and utilization review
				directions, as updated. The provider is responsible for following coding manual
				guidelines and centers for medicare and medicaid services (CMS) correct coding
				initiatives, including not improperly unbundling or upcoding
				services.
B. A provider must verify
				an individual is eligible for a specific MAD service and verify the recipient's
				enrollment status at time of service as well as determining if a copayment is
				applicable or if services require prior authorization. A provider must
				determine if an MAP 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 MAP eligible recipient.
C. Services furnished must be within the
				scope of practice defined by the provider's licensing board, scope of practice
				act, or regulatory authority; see 8.310.3 NMAC.
D. Retention and storage of the original
				prescription, electronic prescription, and records of phone or fax orders must
				meet all pharmacy board requirements and must be retained for six years. If the
				prescriber certifies that a specific brand is medically necessary, by
				handwriting "brand medically necessary" or "brand necessary" on the face of the
				prescription, the allowed ingredient cost is the estimated acquisition cost
				(EAC) of the brand drug. The documentation of the provider's handwritten
				certification must be maintained by the pharmacy provider and furnished upon
				request. Checked boxes, rubber stamps and requests by telephone do not
				constitute appropriate documentation, pursuant to
				42 CFR
				447.512.
"
Brand necessary"
				prescriptions may be subject to prior authorization. Any claim for which "brand
				necessary" is claimed must be supported with documentation in the prescriber's
				medical records. Electronic alternatives approved by the secretary of the
				federal department of health and human services are acceptable.
E. A pharmacy provider must discuss any
				matters with the MAP eligible recipient or their personal representative that
				in the provider's professional judgment are significant. See
				42 USC
				1396 r - 8(g)(2)(A)(ii)(I) of the Social
				Security Act. Pharmacy counseling services are subject to the standards for
				counseling established under the state Pharmacy Practice Act. Counseling must
				be furnished unless declined by the MAP eligible recipient or his or her
				authorized representative.
F. A
				pharmacy must follow all federal and state laws, regulations and rules
				regarding management of pain with controlled substances, use of the drug
				monitoring program database, limiting dispensing of controlled substances, and
				reporting dispensing of controlled substances to state monitoring
				programs.