New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 320 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT) SERVICES › Part 2 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT) SERVICES › Section 8.320.2.14 - GENERAL PROVIDER INSTRUCTION

Current through Register Vol. 35, No. 13, July 16, 2024
A.
				Health care to New Mexico MAP eligible recipients is furnished by a variety of
				providers and provider groups. The reimbursement for these services is
				administered by MAD. Upon approval of a PPA or an electronic health record
				(EHR) incentive payment agreement by MAD or its designee, licensed
				practitioners, facilities and other providers of services that meet applicable
				requirements are eligible to be reimbursed for furnishing MAD covered services
				to MAP eligible recipients. A provider must be approved before submitting a
				claim for payment to the MAD claims processing contractors. When approved, a
				provider receives instruction on how to access these documents, it is the
				provider's responsibility to access these instructions, to understand the
				information provided and to comply with the requirements. The provider must
				contact HSD or its authorized agents to obtain answers to questions related to
				the material or not covered by the material. To be eligible for reimbursement,
				a provider must adhere to the provisions of the MAD PPA and all applicable
				statutes, regulations, rules, and executive orders. MAD or its selected claims
				processing contractor issues payment to a provider using the electronic funds
				transfer (EFT) only. Providers must supply necessary information in order for
				payment to be made.
B. Services
				must be provided within the scope of the practice and licensure for each
				agency, each rendering provider within that agency or each individual provider.
				Services must be in compliance with the statutes, rules and regulations of his
				or her practitioner's applicable practice board and act. Providers must be
				eligible for reimbursement as described in 8.310.3 NMAC.
C. A specific EPSDT service may have
				additional service restrictions listed in the service's non-covered section.
				Generally the following are considered to be noncovered by MAD:
(1) services furnished to an individual who
				is not eligible for MAD EPSDT services;
(2) services furnished without the prior
				authorization of the MAP eligible recipient's primary care provider (PCP) or
				HSD or its designee;
(3) services
				provided by a practitioner who is not in compliance with the statutes,
				regulations, rules or who renders services outside of the scope of practice as
				defined by his or her practice board;
(4) services that are not considered
				medically necessary by MAD or its designee for the condition of the MAP
				eligible recipient;
(5) services
				that are primarily educational or vocational in nature; and
(6) services related to activities for the
				general good and welfare of a MAP eligible recipient, such as general exercises
				to promote overall fitness and flexibility and activities to provide general
				motivation, are not considered physical or occupational therapy for MAD
				reimbursement purposes.