New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 310 - HEALTH CARE PROFESSIONAL SERVICES › Part 2 - GENERAL BENEFIT DESCRIPTION › Section 8.310.2.12 - SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
MAD covers services and procedures that are medically
				  necessary for the diagnosis and treatment of an illness or injury as indicated
				  by the MAP eligible recipient's condition. All services must be furnished
				  within the limits of provider program rules and within the scope of their
				  practice board and licensure.
A.
Medical practitioner services:
(1) Second surgical opinions: MAD covers
				second opinions when surgery is considered.
(2) Services performed in an outpatient
				setting: MAD covers procedures performed in the office, clinic or as outpatient
				institutional services as alternatives to hospitalization. These procedures are
				those for which an overnight stay in a hospital is seldom necessary.
(a) A MAP eligible recipient may be
				hospitalized if they have existing medical conditions that predispose them to
				complications even with minor procedures.
(b) Claims may be subject to pre-payment or
				post-payment review.
(c) Medical
				justification for performance of these procedures in a hospital must be
				documented in the MAP eligible recipient's medical record.
(3) Noncovered therapeutic radiology and
				diagnostic imaging services: MAD does not pay for kits, films or supplies as
				separate charges. All necessary materials and minor services are included in
				the service or procedure charge. Reimbursement for imaging procedures includes
				all materials and minor services necessary to perform the procedure. MAD does
				not pay an additional amount for contrast media except in the following
				instances:
(a) radioactive isotopes;
(b) non-ionic radiographic contrast material;
				or
(c) gadolinium salts used in
				magnetic resonance imaging.
(4) Midwives services: MAD covers services
				furnished by certified nurse midwives or licensed midwives within the scope of
				their practice, as defined by state laws and rules and within the scope of
				their practice board and licensure. Reimbursement for midwife services is based
				on one global fee, which includes prenatal care, delivery and postpartum care.
(a) Separate trimesters completed and routine
				vaginal delivery can be covered if a MAP eligible recipient is not under the
				care of one provider for the entire prenatal, delivery and postpartum
				periods.
(b) MAD covers laboratory
				and diagnostic imaging services related to pregnancy. These services can be
				billed separately.
(c) MAD covers
				gynecological or obstetrical ultrasounds without requiring a prior
				authorization of any kind.
(d) MAD
				covers a MAP eligible pregnant recipient's labor and delivery services at a New
				Mexico department of health (DOH) licensed birth center through the "Birthing
				Options Program" (BOP). MAD reimburses the birth center facility and the
				rendered services of a midwife separately. BOP services are provided by an
				eligible midwife that enrolls as a BOP provider with the human services
				department/medical assistance division (HSD/MAD). The facility must comply with
				all DOH licensing requirements, including limiting licensure. The facility must
				maintain all clinical documentation, including schedules, for the period of
				time as required under 8.302.1 NMAC. The program does not cover the full scope
				of midwifery services nor replace pediatric care that should occur at a primary
				care clinic.
(e) Non-covered
				midwife services: Midwife services are subject to the limitation and coverage
				restrictions which exist for other MAD services. MAD does not cover the
				following specific services furnished by a midwife:
(i) oral medications or medications, such as
				ointments, creams, suppositories, ophthalmic and otic preparations which can be
				appropriately self-administered by the MAP eligible recipient;
(ii) services furnished by an apprentice;
				unless billed by the supervising midwife;
(iii) an assistant at a home birth unless
				necessary based on the medical condition of the MAP eligible recipient which
				must be documented in the claim.