New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 311 - HOSPITAL SERVICES › Part 2 - HOSPITAL SERVICES › Section 8.311.2.16 - EMERGENCY ROOM SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
MAD covers emergency room services which are medically
				  necessary for the diagnosis and treatment of medical or surgical emergencies to
				  an eligible recipient and which are within the scope of the MAD program.
A. Covered emergency services: An emergency
				condition is a medical or behavioral health condition manifesting itself by
				acute symptoms of sufficient severity (including severe pain) such that a
				prudent layperson, who possesses an average knowledge of health and medicine
				could reasonably expect the absence of immediate medical attention to result in
				placing the health of the individual (or with respect to a pregnant woman, the
				health of the woman or her unborn child) in serious jeopardy, serious
				impairment to body function or serious dysfunction of any bodily organ or
				part.
B. Retrospective review: An
				emergency room service may be subject to prepayment or post-payment review. A
				provider, including an enrolled provider, a non-enrolled provider, a managed
				care organization provider, or an out of network provider cannot bill an
				eligible recipient for emergency room services including diagnostic and
				ancillary services which have been denied due to lack of medical necessity or
				lack of being an emergency except as specifically allowed by 8.302.2 NMAC,
Billing for Medicaid Services
. When an eligible recipient has
				identified himself or herself to a provider as a medicaid eligible recipient
				and is enrolled in a managed care organization, the provider of services must
				accept and adhere to the provisions of 42 CFR 438 Subpart C Enrollee Rights and
				Protections which state the administrative and payment responsibilities of a
				managed care organization and limit the financial responsibilities that can be
				passed on to an eligible recipient. Payment may be limited to medically
				necessary diagnostic and treatment services to sufficiently assess the
				recipient's condition and need for emergency services, the duration of a
				condition, and available alternatives to emergency room services.
C. Prior authorization: Some services or
				procedures performed in an emergency room setting need prior approval from MAD
				or its designee. Procedures that require prior approval in nonemergency
				settings also require prior approval in emergency settings.
D. Noncovered emergency services: MAD does
				not cover the following specific emergency services:
(1) diagnostic and other ancillary services
				which are not considered medically necessary as emergency services;
(2) emergency services furnished to
				individuals who were not eligible for MAD services on the date of
				service;
(3) experimental or
				investigational procedures, technologies or therapies and the services related
				to them, including hospitalization, anesthesiology, laboratory tests and
				imaging services; see 8.325.6 NMAC,
Experimental or Investigational
				Procedures or Therapies
;
(4) drugs classified as "ineffective" by the
				federal food and drug administration; and
(5) laboratory specimen handling or mailing
				charges.