reglab/statecodes huggingface dataset:
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 300 - MEDICAID GENERAL INFORMATION › Part 11 - CONFIDENTIALITY › Section 8.300.11.3 - STATUTORY AUTHORITY

Current through Register Vol. 35, No. 13, July 16, 2024
The New Mexico medicaid program is administered pursuant to
				  regulations promulgated by the federal department of health and human services
				  under Title XIX of the Social Security Act as amended and by state statute. See
				  Section 27-2-12 et seq. NMSA 1978 (Repl. Pamp. 1991). Section 9-8-1 et seq.
				  NMSA 1978 establishes the health care authority (HCA) as a single, unified
				  department to administer laws and exercise functions relating to health care
				  facility licensure and health care purchasing and regulation.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 300 - MEDICAID GENERAL INFORMATION › Part 11 - CONFIDENTIALITY › Section 8.300.11.8 - MISSION STATEMENT

Current through Register Vol. 35, No. 13, July 16, 2024
The mission of the New Mexico medical assistance division
				  (MAD) is to maximize the health status of eligible recipients by furnishing
				  payment for quality health services at levels comparable to private health
				  plans.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 300 - MEDICAID GENERAL INFORMATION › Part 11 - CONFIDENTIALITY › Section 8.300.11.9 - CONFIDENTIALITY

Current through Register Vol. 35, No. 13, July 16, 2024
The following applicant and eligible recipient information is
				  confidential and is safeguarded by the HCA, all state agencies, their
				  contractors and other authorized agents and all providers of MAD services. See
				  42 CFR
				  431.305(b) and
				  45 CFR
				  164.530(c):
A. name, address and social security
				number;
B. medical services
				furnished to the applicant and eligible recipient;
C. social and economic conditions or
				circumstances;
D. agency evaluation
				of personal information;
E. medical
				data, including diagnosis and past history of disease or disability;
F. information received to verify income
				eligibility and the amount of medical payments, including information received
				from the social security administration and the internal revenue
				service;
G. information received in
				connection with the identification of legally liable third parties;
H. telephone numbers;
I. fax numbers;
J. electronic mail addresses;
K. medical record numbers;
L. health plan beneficiary numbers;
M. account numbers; and
N. certificate/license numbers.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 300 - MEDICAID GENERAL INFORMATION › Part 11 - CONFIDENTIALITY › Section 8.300.11.10 - CONFIDENTIALITY OF APPLICANT/RECIPIENT INFORMATION

Current through Register Vol. 35, No. 13, July 16, 2024
A. Safeguarding of confidential applicant and
				eligible recipient information includes the methods of receiving, maintaining,
				and communicating individually identifiable health information. See
				45 CFR Section
				164.530(c).
B. Confidentiality of medical information:
				Confidential information regarding applicants or eligible recipients will be
				available to those identified in
				8.300.11.9 NMAC for use only in
				connection with the administration of the New Mexico medical assistance
				programs and only on a need-to-know basis. See 42 CFR Section 431.300-307 .
				Those using confidential information will only use the minimum necessary to
				accomplish the intended purpose of the use, disclosure, or request. See
				45 CFR Section
				164.502(b).
C. Use of confidential medical information:
				The following individuals have access to medical information: employees of
				private firms, other divisions within HCA or other state agencies who are
				performing work or providing services for MAD under contract or business
				associate agreement or who are providing services, as required by federal law;
				employees or agents of the federal department of health and human services; and
				providers of health care services to eligible recipients.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 300 - MEDICAID GENERAL INFORMATION › Part 11 - CONFIDENTIALITY › Section 8.300.11.11 - CONFIDENTIALITY OF ELECTRONIC DATA

Current through Register Vol. 35, No. 13, July 16, 2024
A.
				Electronic transmission/reception of confidential information: To ensure that
				the confidential medical information of eligible recipients and applicants is
				kept confidential, transmission and reception of this information is limited to
				those individuals allowed to have access to medical information as stated in
				the use of confidential medical information policy (Paragraph (1) of Subsection
				B of 8.300.11.10 NMAC) and safeguarding
				protected health information policy
				8.300.2.22 NMAC).
B. Provider participation: Providers who
				choose to send or receive confidential medical information via fax must have a
				dedicated fax line or fax machine. Confidential medical information should not
				be received at a commercial fax center where employees or customers may have
				access to the information. Providers who choose to send or receive confidential
				medical information via fax or email must follow the minimum necessary
				standard. See 45 CFR Section
				164.502.
C. Responsibility for failure to follow rule:
				Providers who fail to adhere to this rule are solely liable for any
				consequences resulting from the use of this method of transmitting confidential
				medical information, including any attorney fees, costs or damages. MAD shall
				mitigate any harmful effect from improper disclosure of individually
				identifiable health information in accordance with
				45 CFR Section
				164.530(f).
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 300 - MEDICAID GENERAL INFORMATION › Part 17 - CONFLICT OF INTEREST › Section 8.300.17.3 - STATUTORY AUTHORITY

Current through Register Vol. 35, No. 13, July 16, 2024
The New Mexico medicaid program is administered pursuant to
				  regulations promulgated by the federal department of health and human services
				  under Title XIX of the Social Security Act, as amended, and by the state health
				  care authority pursuant to state statute. See Section 27-2-12 et seq. NMSA 1978
				  (Repl. Pamp. 1991). Section 9-8-1 et seq. NMSA 1978 establishes the health care
				  authority (HCA) as a single, unified department to administer laws and exercise
				  functions relating to health care facility licensure and health care purchasing
				  and regulation.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 300 - MEDICAID GENERAL INFORMATION › Part 17 - CONFLICT OF INTEREST › Section 8.300.17.6 - OBJECTIVE

Current through Register Vol. 35, No. 13, July 16, 2024
The objective of these regulations is to provide policies for
				  the service portion of the New Mexico medicaid program. These policies describe
				  eligible providers, covered services, noncovered services, utilization review,
				  and provider reimbursement.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 300 - MEDICAID GENERAL INFORMATION › Part 17 - CONFLICT OF INTEREST › Section 8.300.17.8 - MISSION STATEMENT

Current through Register Vol. 35, No. 13, July 16, 2024
The mission of the New Mexico medical assistance division
				  (MAD) is to maximize the health status of medicaid-eligible individuals by
				  furnishing payment for quality health services at levels comparable to private
				  health plans.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 300 - MEDICAID GENERAL INFORMATION › Part 17 - CONFLICT OF INTEREST › Section 8.300.17.9 - CONFLICT OF INTEREST

Current through Register Vol. 35, No. 13, July 16, 2024
To prevent any former employee of the medical assistance
				  division (MAD) from using privileged information or asserting improper
				  influence, statutory provisions have been adopted. See Section 10-16-16 NMSA
				  1978 (Repl. Pamp. 1991):
A. An
				employee with "responsibility" must not act as agent or attorney for any other
				person or business in connection with a judicial or administrative proceeding,
				application, ruling, contract, claim or other matter relative to the medicaid
				program for 24 months following the date on which they cease to be an employee.
(1) Employee with "responsibility" refers to
				an employee who is directly involved in or has a significant part in the
				medicaid decision-making, regulatory, procurement or contracting
				process.
(2) This provision applies
				to employees with responsibility for investigating, making rulings or otherwise
				being substantially or directly involved with activities during their last year
				of employment with the agency.
(3)
				This provision also applies to activities which were actually pending and under
				the employee's responsibility within that period.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 300 - MEDICAID GENERAL INFORMATION › Part 17 - CONFLICT OF INTEREST › Section 8.300.17.10 - PENALTIES

Current through Register Vol. 35, No. 13, July 16, 2024
Violation of any of the above provisions by an employee is
				  grounds for dismissal, demotion or suspension. A former employee who violates
				  any of the provisions is subject to assessment by the HCA of a civil monetary
				  penalty of $250 for each violation. MAD shall mitigate any harmful effect from
				  improper disclosure of individually identifiable health information in
				  accordance with 45 CFR
				  Section 164.530(f). Any
				  employee or former employee who violates these provisions may also be subject
				  to criminal prosecution. See Section 10-16-17 NMSA 1978 (Cum. Supp.
				  1993).
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 300 - MEDICAID GENERAL INFORMATION › Part 17 - CONFLICT OF INTEREST › Section 8.300.17.11 - APPEAL PROCESS

Current through Register Vol. 35, No. 13, July 16, 2024
A request for appeal from the imposition of an administrative
				  sanction must be made to the secretary within 30 days of the date on the
				  written notification of a penalty assessment. Unless a proper request is
				  received by the secretary within the 30 day limit, the HCA findings are
				  considered a final and binding administrative determination.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 300 - MEDICAID GENERAL INFORMATION › Part 21 - MEDICAL ASSISTANCE DIVISION POLICY MANUAL › Section 8.300.21.3 - STATUTORY AUTHORITY

Current through Register Vol. 35, No. 13, July 16, 2024
The New Mexico medicaid program is administered pursuant to
				  regulations promulgated by the federal department of health and human services
				  under Title XIX of the Social Security Act as amended, or by state statute. See
				  Section 27-212 et seq. NMSA 1978 (Repl. Pamp. 2007). Section 9-8-1 et seq. NMSA
				  1978 establishes the health care authority (HCA) as a single, unified
				  department to administer laws and exercise functions relating to health care
				  facility licensure and health care purchasing and regulation.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 300 - MEDICAID GENERAL INFORMATION › Part 21 - MEDICAL ASSISTANCE DIVISION POLICY MANUAL › Section 8.300.21.5 - EFFECTIVE DATE

Current through Register Vol. 35, No. 13, July 16, 2024
July 1, 2024, unless a later date is cited at the end of a
				  section.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 300 - MEDICAID GENERAL INFORMATION › Part 21 - MEDICAL ASSISTANCE DIVISION POLICY MANUAL › Section 8.300.21.6 - OBJECTIVE

Current through Register Vol. 35, No. 13, July 16, 2024
The objective of these rules is to provide instruction for
				  the service portion of the New Mexico medical assistance
				  programs.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 300 - MEDICAID GENERAL INFORMATION › Part 21 - MEDICAL ASSISTANCE DIVISION POLICY MANUAL › Section 8.300.21.8 - MISSION STATEMENT

Current through Register Vol. 35, No. 13, July 16, 2024
The mission of the New Mexico medical assistance division
				  (MAD) is to maximize the health status of eligible recipients by furnishing
				  payment for quality health services at levels comparable to private health
				  plans.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 300 - MEDICAID GENERAL INFORMATION › Part 21 - MEDICAL ASSISTANCE DIVISION POLICY MANUAL › Section 8.300.21.9 - MEDICAL ASSISTANCE DIVISION POLICY MANUAL

Current through Register Vol. 35, No. 13, July 16, 2024
The MAD rule manual (the manual) contains detailed
				  information about the New Mexico medical assistance programs. It is intended
				  for use by all participating providers who furnish health services, MAD
				  applicants/recipients, HCA employees and designees, contractors, and all other
				  interested parties.
A. Purpose of the
				manual: The purpose of the manual is to provide an overview of general rules on
				the administration and financing of medicaid and other health care programs
				administered by MAD, recipient eligibility, coverage of services, and
				reimbursement by provider group. Once enrolled, MAD providers receive
				instructions on how to access instructions, and other pertinent materials. The
				MAD eligibility manual sections are available at the HCA website or other
				program specific websites.
B.
				Updating manual: To ensure that MAD rules contained in this manual remains
				current, providers, local county ISD offices, and other interested parties on
				the mailing list are notified of updates at the conclusion of the publication
				process. The finalized rules are available on the HCA website or other program
				specific websites for viewing and copying.
(1)
				Rule updates are distributed in the form of New Mexico medical assistance
				manual revisions (MAD-MR). Each MAD-MR provides the rationale for the rule
				revision, specific changes, and instructions for updating the affected manual
				sections.
(2) Updates for claims
				processing, prior authorization, and utilization review instructions for
				providers are distributed in the form of MAD supplements.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 300 - MEDICAID GENERAL INFORMATION › Part 22 - ELECTRONIC HEALTH RECORDS INCENTIVE PROGRAM › Section 8.300.22.3 - STATUTORY AUTHORITY

Current through Register Vol. 35, No. 13, July 16, 2024
The New Mexico medicaid program and other health care
				  programs are administered pursuant to regulations promulgated by the federal
				  department of health and human services under Title XIX of the Social Security
				  Act as amended or by state statute. See NMSA 1978, Section 27/1/2012 et seq.
				  Section 9-8-1 et seq. NMSA 1978 establishes the health care authority (HCA) as
				  a single, unified department to administer laws and exercise functions relating
				  to health care facility licensure and health care purchasing and
				  regulation.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 300 - MEDICAID GENERAL INFORMATION › Part 22 - ELECTRONIC HEALTH RECORDS INCENTIVE PROGRAM › Section 8.300.22.5 - EFFECTIVE DATE

Current through Register Vol. 35, No. 13, July 16, 2024
August 1, 2011, unless a later date is cited at the end of a
				  section.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 300 - MEDICAID GENERAL INFORMATION › Part 22 - ELECTRONIC HEALTH RECORDS INCENTIVE PROGRAM › Section 8.300.22.6 - OBJECTIVE

Current through Register Vol. 35, No. 13, July 16, 2024
The objective of this rule is to provide instructions for the
				  service portion of the New Mexico medical assistance division
				  programs.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 300 - MEDICAID GENERAL INFORMATION › Part 22 - ELECTRONIC HEALTH RECORDS INCENTIVE PROGRAM › Section 8.300.22.8 - MISSION STATEMENT

Current through Register Vol. 35, No. 13, July 16, 2024
To reduce the impact of poverty on people living in New
				  Mexico by providing support services that help families break the cycle of
				  dependency on public assistance.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 300 - MEDICAID GENERAL INFORMATION › Part 22 - ELECTRONIC HEALTH RECORDS INCENTIVE PROGRAM › Section 8.300.22.9 - ELECTRONIC HEALTH RECORDS INCENTIVE PROGRAM

Current through Register Vol. 35, No. 13, July 16, 2024
The New Mexico medical assistance division (MAD) administers
				  the medicaid electronic health records incentive program (medicaid EHR
				  incentive program) as authorized by the federal American Recovery and
				  Reinvestment Act of 2009. Under this program, New Mexico MAD providers may
				  qualify for incentive payments if they meet the eligibility guidelines in this
				  section and demonstrate they are engaged in efforts to adopt, implement,
				  upgrade (AIU), or meaningfully use certified electronic health records (EHR)
				  technology. The medicaid EHR incentive program is governed by the rule in this
				  section, the electronic health records program final rule issued by centers for
				  medicare and medicaid (CMS) in CMS-0033-F and 45 CFR 170, and the conditions of
				  approval of the MAD plan approved by CMS. New Mexico MAD providers must also
				  follow MAD instructions for enrolling in the medicaid EHR incentive program and
				  provide documentation as required. Payments are made with federal funds and are
				  contingent on the availability of those funds and federal requirements for
				  reimbursement. Should the federal government discontinue funding, the incentive
				  payments, inclusive, then incentive payments from the department will
				  terminate.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 300 - MEDICAID GENERAL INFORMATION › Part 22 - ELECTRONIC HEALTH RECORDS INCENTIVE PROGRAM › Section 8.300.22.11 - ELIGIBLE RECIPIENT VOLUME

Current through Register Vol. 35, No. 13, July 16, 2024
An eligible professional provider and an eligible hospital
				  must meet eligible recipient volume criteria to qualify for incentive payments.
				  Eligible recipient volume criteria compliance will be verified by MAD through
				  claims and encounter data and audits. Eligible recipient volume requirements
				  represent Title XIX (medicaid) eligible recipients as a percent of total
				  eligible recipients, except for an eligible professional provider practicing
				  predominately in a FQHC or RHC, who may use "needy individuals" as defined
				  below in calculating eligible recipient volume.
A. The CMS final rule provides two options
				for determining patient volume percentages. New Mexico MAD will allow both
				options, as described below:
(1) eligible
				recipient encounter method: medicaid eligible recipient encounters in any
				90-day reporting period in the preceding calendar year divided by total
				eligible recipient encounters in same 90-day period; or
(2) unduplicated eligible recipient method:
				see formula below.
(total medicaid eligible recipients assigned to the provider
				  in any representative continuous 90-day period in the preceding calendar year
				  with at least one encounter in the year preceding the start of the 90-day
				  period) + (unduplicated medicaid encounters in that same 90-day period) *100
				  divided by (total eligible recipients assigned to the provider in the same 90
				  days with at least one encounter in the year preceding the start of the 90-day
				  period) + (all unduplicated encounters in that same 90-day period).
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 300 - MEDICAID GENERAL INFORMATION › Part 22 - ELECTRONIC HEALTH RECORDS INCENTIVE PROGRAM › Section 8.300.22.12 - NATIONAL REGISTRATION AND ATTESTATION SYSTEM

Current through Register Vol. 35, No. 13, July 16, 2024
An eligible professional provider or eligible hospital
				  choosing to participate in the medicaid EHR incentive program must register
				  with the CMS national level registry (NLR) and provide demographic information
				  as well as participation choices. The NLR registration process is described in
				  the medicaid EHR incentive program participation
				  instructions.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 300 - MEDICAID GENERAL INFORMATION › Part 22 - ELECTRONIC HEALTH RECORDS INCENTIVE PROGRAM › Section 8.300.22.13 - ATTESTATION REQUIREMENTS

Current through Register Vol. 35, No. 13, July 16, 2024
An eligible professional provider or eligible hospital must
				  attest to meeting the medicaid EHR incentive program participation requirements
				  as a prerequisite to receiving payment. Attestation is accomplished through
				  on-line access to the state level registry (SLR) and completion of an
				  agreement. The agreement must be signed by the eligible professional provider
				  or the eligible hospital and when accepted by MAD becomes part of the MAD
				  provider participation agreement or a MAD EHR incentive payment agreement. The
				  medicaid EHR incentive program attestation includes several elements, described
				  in subsequent sections.
A. An eligible
				professional provider or eligible hospital in their first participation year
				under the medicaid EHR incentive program may choose to attest to adopting,
				implementing, or upgrading certified electronic health record (EHR) technology.
				Proof of A/I/U must be submitted to MAD as part of the attestation.
B. An eligible professional provider in their
				second through sixth participation year and an eligible hospital in their
				second through third, or fourth participation year must attest to meaningful
				use of certified EHR technology. An eligible hospital must attest to meaningful
				use if they are participating in both the medicare and MAD medicaid EHR
				incentive programs in their first participation year. The definition of
				"meaningful EHR user" and "meaningful use" is found in
				42
				CFR 495.4 and
				42
				CFR 495.6, respectively.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 300 - MEDICAID GENERAL INFORMATION › Part 22 - ELECTRONIC HEALTH RECORDS INCENTIVE PROGRAM › Section 8.300.22.14 - PAYMENT REQUIREMENTS

Current through Register Vol. 35, No. 13, July 16, 2024
An eligible professional provider and eligible hospital may
				  receive yearly payments under the medicaid EHR incentive program. All medicaid
				  EHR incentive program payments are subject to certain conditions.
A. Attestations must be accepted by MAD and
				the attested items verified pursuant to MAD guidelines.
B. An eligible professional provider or
				eligible hospital must identify a taxpayer identification number (TIN) to
				assign payment. Valid entities may be the individual eligible professional
				provider, a group with which the eligible professional provider s associated or
				an organization recognized by MAD as a qualified organization promoting the use
				of EHR technology. The "qualified organization" may not retain more than five
				percent of the annual medicaid EHR incentive program for those costs unrelated
				to the certified EHR, which will include salaries and benefits, rent,
				maintenance, utilities, insurance and travel.
C. The eligible professional or eligible
				hospital must have a current MAD provider participation agreement or a MAD EHR
				incentive payment agreement by MAD or its designee.
D. The eligible professional provider or
				eligible hospital is responsible for repayment of any identified overpayment of
				the medicaid EHR incentive program funds. MAD will recoup the overpaid funds by
				reducing any future payments, or through other arrangements as it
				determines.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 300 - MEDICAID GENERAL INFORMATION › Part 22 - ELECTRONIC HEALTH RECORDS INCENTIVE PROGRAM › Section 8.300.22.15 - PAYMENT CALCULATION

Current through Register Vol. 35, No. 13, July 16, 2024
MAD will calculate yearly payment amounts and the total
				  payment amounts based on the guidelines described below.
A. An eligible professional provider may
				receive a maximum of $63,750 in the incentive payments over six years, unless
				otherwise reduced or increased by CMS.
(1) An
				eligible professional provider must initiate registration to receive payment in
				2016 in order to participate in the program.
(2) An eligible professional provider may
				receive payment on an annual or non-consecutive basis for up to six years
				between 2011 through 2021.
(3)
				Payment will be made one time per year per eligible professional
				provider.
(4) To receive an
				incentive payment in the second, third, fourth, fifth and sixth payment year,
				the eligible professional provider must demonstrate that it is a meaningful
				user of EHR technology, as described in
				42
				CFR 495.4.
PY 2011
PY 2012
PY 2013
PY 2014
PY 2015
PY 2016
CY 2011
$21,250
CY 2012
$8,500
$21,250
CY 2013
$8,500
$8,500
$21,250
CY 2014
$8,500
$8,500
$8,500
$21,250
CY 2015
$8,500
$8,500
$8,500
$8,500
$21,250
CY 2016
$8,500
$8,500
$8,500
$8,500
$8,500
$21,250
CY 2017
$8,500
$8,500
$8,500
$8,500
$8,500
CY 2018
$8,500
$8,500
$8,500
$8,500
CY 2019
$8,500
$8,500
$8,500
CY 2020
$8,500
$8,500
CY 2021
$8,500
Potential:
$63,750
$63,750
$63,750
$63,750
$63,750
$63,750
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 300 - MEDICAID GENERAL INFORMATION › Part 22 - ELECTRONIC HEALTH RECORDS INCENTIVE PROGRAM › Section 8.300.22.16 - AUDIT AND RECORD RETETION

Current through Register Vol. 35, No. 13, July 16, 2024
Medicaid EHR incentive program participation and payments are
				  subject to audit and recoupment if determined to be paid improperly. MAD will
				  provide both prepayment verification and post payment audit of the payments
				  made through the medicaid EHR incentive program.
A. MAD expects to verify most aspects of
				medicaid EHR incentive program eligibility as part of its pre-payment
				screening, including:
(1) active MAD provider
				participation agreement for an eligible professional provider and an eligible
				hospital or a MAD EHR incentive payment agreement;
(2) MAD eligible recipient volume for an
				eligible professional provider in an independent practice (broken out by FFS
				and for each contracted MCO);
(3)
				participation in the group practice identified by the eligible professional
				provider as meeting the threshold for MAD eligible recipient volume;
(4) total MAD eligible recipient for group
				practice;
(5) all members of a
				group use the same methodology for assigning eligible recipients to
				participating eligible professional providers;
(6) A/I/U certified EHR software for eligible
				professionals;
(7) not a hospital
				based provider for eligible professional providers;
(8) hospital eligible recipient volume from
				audit reports; and
(9) hospital
				incentive payment calculation (one-time process).
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 301 - MEDICAID GENERAL BENEFIT DESCRIPTION › Part 5 - MEDICAL MANAGEMENT › Section 8.301.5.3 - STATUTORY AUTHORITY

Current through Register Vol. 35, No. 13, July 16, 2024
The New Mexico medicaid program is administered pursuant to
				  regulations promulgated by the federal department of health and human services
				  under Title XIX of the Social Security Act, as amended, and by the state health
				  care authority pursuant to state statute. See 27-2-12 et. seq. NMSA 1978 (Repl.
				  Pamp. 1991). Section 9-81 et seq. NMSA 1978 establishes the health care
				  authority (HCA) as a single, unified department to administer laws and exercise
				  functions relating to health care facility licensure and health care purchasing
				  and regulation.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 301 - MEDICAID GENERAL BENEFIT DESCRIPTION › Part 5 - MEDICAL MANAGEMENT › Section 8.301.5.6 - OBJECTIVE

Current through Register Vol. 35, No. 13, July 16, 2024
The objective of these regulations is to provide policies for
				  the service portion of the New Mexico medicaid program. These policies describe
				  eligible providers, covered services, noncovered services, utilization review,
				  and provider reimbursement.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 301 - MEDICAID GENERAL BENEFIT DESCRIPTION › Part 5 - MEDICAL MANAGEMENT › Section 8.301.5.8 - MISSION STATEMENT

Current through Register Vol. 35, No. 13, July 16, 2024
The mission of the New Mexico medical assistance division
				  (MAD) is to maximize the health status of medicaid-eligible individuals by
				  furnishing payment for quality health services at levels comparable to private
				  health plans.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 301 - MEDICAID GENERAL BENEFIT DESCRIPTION › Part 5 - MEDICAL MANAGEMENT › Section 8.301.5.9 - MEDICAL MANAGEMENT

Current through Register Vol. 35, No. 13, July 16, 2024
The New Mexico medicaid program (medicaid) pays for medically
				  necessary medical services furnished to medicaid recipients. To make sure that
				  recipients receive only necessary services, the New Mexico medical assistance
				  division (MAD) has developed the medical management program. The medical
				  management program is designed to enhance the receipt of health care to a
				  recipient by assigning a designated provider. This may also reduce the use of
				  unnecessary services by medicaid recipients in certain instances. See
				  42 CFR
				  431.54(e). Medical
				  management involves the identification of appropriate cases, selection of
				  actual cases, documentation of the health care issue(s) necessitating
				  management, development of assignment recommendations, and evaluation of the
				  effectiveness of the assignments. The medical assistance division (MAD) medical
				  director or another physician specifically appointed by MAD determines whether
				  recipients are assigned to the medical management program.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 301 - MEDICAID GENERAL BENEFIT DESCRIPTION › Part 5 - MEDICAL MANAGEMENT › Section 8.301.5.10 - SERVICES EXCLUDED FROM MEDICAL MANAGEMENT

Current through Register Vol. 35, No. 13, July 16, 2024
Recipients can receive emergency services and inpatient
				  services without referrals from their designated providers. These services are
				  exempt from medical management. Emergency room claims for services provided to
				  any recipient may be reviewed before or after payment. Inappropriate
				  nonemergency use of emergency room services results in denial of payment by
				  medicaid and liability of the recipient for payment.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 301 - MEDICAID GENERAL BENEFIT DESCRIPTION › Part 5 - MEDICAL MANAGEMENT › Section 8.301.5.11 - IDENTIFICATION OF CANDIDATES

Current through Register Vol. 35, No. 13, July 16, 2024
All medicaid recipients are potential candidates for
				  inclusion in medical management, whether enrolled in Salud! or covered under
				  medicaid fee-for-service.
Recipients are identified as candidates for review by HCA,
				  the MCO, a provider or other appropriate entities. The following situations may
				  indicate a need for medical management:
A. individuals who overutilize medical
				services;
B. individuals who are
				habitually non-compliant and miss appointments, or who frequently seek
				unauthorized treatment or care; and
C. individuals who frequently change PCPs or
				simultaneously utilize multiple pharmacy providers;
D. individuals who regularly utilize
				emergency room services for inappropriate, nonemergency care.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 301 - MEDICAID GENERAL BENEFIT DESCRIPTION › Part 5 - MEDICAL MANAGEMENT › Section 8.301.5.12 - SELECTION FOR MEDICAL MANAGEMENT

Current through Register Vol. 35, No. 13, July 16, 2024
HCA staff analyzes appropriate reports and documentation to
				  decide whether a recipient will be referred to the MAD medical director for
				  medical management determination. After reviewing HCA staff recommendations and
				  supporting documentation, the MAD medical director or another physician
				  designated by MAD determines whether the recipient should be assigned to
				  medical management. Once the determination is made by the physician, the
				  assignment of the recipient to medical management is implemented by MAD. The
				  assignment is subject to the notice requirements and hearing process described
				  below in Section 15,
Recipient Notice
and Section 16,
Recipient Hearings
.
A. Notification of decision: The HCA staff
				notifies the recipient, the claims processing contractor, the income support
				division (ISD), and, if enrolled in Salud!, the MCO, of the medical management
				assignments. Providers are informed that a client is in medical management at
				the time the provider verifies the client's eligibility for the date the
				services are provided. Recipients placed in medical management receive medicaid
				identification cards which indicate "medical management" and the names of their
				"designated providers".
B.
				Assignments for recipients covered by third party insurers: Recipients who are
				eligible for medicare and medicaid services or recipients who have insurance
				can be assigned to a designated provider for services covered exclusively by
				medicaid. Recipients in managed care plans are assigned to designated providers
				who participate in the recipient's plan.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 301 - MEDICAID GENERAL BENEFIT DESCRIPTION › Part 5 - MEDICAL MANAGEMENT › Section 8.301.5.13 - DESIGNATED PROVIDERS

Current through Register Vol. 35, No. 13, July 16, 2024
Recipients who are in medical management are assigned to
				  designated providers based on their specific health care situation. Recipients
				  may be assigned to a designated provider who manages the recipient's overall
				  receipt of health services by making referrals, a designated provider who
				  furnishes only specialty services, or both. Medicaid payment for medical
				  services is restricted to designated providers. Other providers can receive
				  payment for services furnished to a recipient in medical management only with a
				  referral from the designated provider. If a recipient is assigned a designated
				  psychiatrist, only that psychiatrist is reimbursed by medicaid or the MCO for
				  providing outpatient psychiatric services to the recipient, unless the
				  designated psychiatrist determines that it is medically necessary for the
				  recipient to be referred to a second psychiatrist. If a recipient is assigned a
				  designated general provider, only that provider is reimbursed by medicaid or
				  the MCO for providing outpatient services to the recipient, unless the
				  designated general provider determines that it is medically necessary for the
				  recipient to be referred to a secondary provider. If a recipient is assigned a
				  designated pharmacy provider, only that provider is reimbursed by medicaid
				  fee-for-service or the MCO.
A.
				Selection of designated providers: Providers of outpatient services are
				selected as "designated providers". The following guidelines are used to select
				a provider:
(1) the provider must be a
				medicaid fee-for-service or MCO contracted provider;
(2) the provider agrees to act in the
				capacity of a designated provider;
(3) the geographic location of the provider
				must not significantly impair or impede the recipient's access to services;
				and
(4) when feasible, the provider
				is one with whom the recipient has previously established a
				medically-beneficial relationship;
(5) if the designated provider is not the
				recipient's PCP, then the provider must coordinate with the recipient's
				PCP.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 301 - MEDICAID GENERAL BENEFIT DESCRIPTION › Part 5 - MEDICAL MANAGEMENT › Section 8.301.5.14 - REEVALUATION OF ASSIGNMENT

Current through Register Vol. 35, No. 13, July 16, 2024
Initial medical management assignments are reevaluated by the
				  HCA staff within a year of the effective date of the assignment or from the
				  date of reevaluation. The reevaluation focuses on whether assignments met the
				  objectives identified in the HCA staff recommendation or whether the initial
				  assignments need modification. A reevaluation is conducted using information
				  similar to that used in the initial medical management assignment analysis. If
				  continuation or modification of an assignment is necessary, the reasons for the
				  action are documented in the case file. The MAD medical director or another
				  physician designated by MAD makes the final decision as to whether the
				  assignment needs to be continued, modified or removed.
A. Medicaid eligibility changes: Changes in
				recipient eligibility status do not affect the status of a recipient in medical
				management or the reevaluation process. If a recipient on medical management
				becomes ineligible for medicaid benefits but later becomes medicaid eligible
				within the assignment period, the recipient remains in medical
				management.
B. Removal from the
				medical management program: Recipients are removed from medical management by
				HCA staff when the specific situation necessitating medical management has been
				resolved.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 301 - MEDICAID GENERAL BENEFIT DESCRIPTION › Part 5 - MEDICAL MANAGEMENT › Section 8.301.5.15 - RECIPIENT NOTICE

Current through Register Vol. 35, No. 13, July 16, 2024
The medical assistance division gives a recipient and the
				  MCO, if the recipient is enrolled in Salud!, 13 working days notice of the
				  decision to place the recipient in medical management. Notice is given for the
				  initial imposition of the assignment, modification of the assignment, or
				  continuation of the assignment.
A.
				Time constraints: A recipient can submit a request for a hearing of their
				assignment into medical management, assignment of the designated providers,
				modification, or continuation of the assignment. If the recipient requests a
				hearing within the time frame established below in Section 16,
Recipient Hearing
, the proposed assignment shall remain
				imposed until a hearing decision states otherwise.
B. Information contained in the notice: The
				recipient notice contains the following information
				42 CFR
				431.210:
(1) statement describing the action MAD
				intends to take;
(2) reasons for
				the intended action;
(3) specific
				state or federal regulations supporting the action or change(s) in the law
				which require the action;
(4)
				explanation of the recipient's right to request an administrative hearing and
				the method and timetable by which the hearing can be requested;
(5) statement explaining the recipient's
				right to be represented at the administrative hearing by legal counsel, a
				friend, or other representative;
(6) explanation of the circumstances under
				which the benefits are continued; and
(7) effective date of the
				assignment.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 301 - MEDICAID GENERAL BENEFIT DESCRIPTION › Part 5 - MEDICAL MANAGEMENT › Section 8.301.5.16 - RECIPIENT HEARING

Current through Register Vol. 35, No. 13, July 16, 2024
A recipient has a right to request a hearing regarding the
				  MAD decision to assign the recipient into medical management. The request must
				  be submitted to the quality assurance bureau of MAD, the HCA hearing bureau or
				  the local ISD office within 90 days of the date the notice of action was
				  postmarked. See 8.352.2 NMAC,
Recipient
				  Hearings
.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 301 - MEDICAID GENERAL BENEFIT DESCRIPTION › Part 6 - CLIENT MEDICAL TRANSPORTATION SERVICES › Section 8.301.6.3 - STATUTORY AUTHORITY

Current through Register Vol. 35, No. 13, July 16, 2024
The New Mexico medicaid and other health care programs are
				  administered pursuant to regulations promulgated by the federal department of
				  health and human services under the Social Security Act as amended, or by state
				  statute. See Section 27-1-12 et seq. NMSA 1978. Section 9-8-1 et seq. NMSA 1978
				  establishes the health care authority (HCA) as a single, unified department to
				  administer laws and exercise functions relating to health care facility
				  licensure and health care purchasing and regulation.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 301 - MEDICAID GENERAL BENEFIT DESCRIPTION › Part 6 - CLIENT MEDICAL TRANSPORTATION SERVICES › Section 8.301.6.5 - EFFECTIVE DATE

Current through Register Vol. 35, No. 13, July 16, 2024
July 1, 2024, unless a later date is cited at the end of a
				  section.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 301 - MEDICAID GENERAL BENEFIT DESCRIPTION › Part 6 - CLIENT MEDICAL TRANSPORTATION SERVICES › Section 8.301.6.6 - OBJECTIVE

Current through Register Vol. 35, No. 13, July 16, 2024
The objective of this rule is to provide instruction for the
				  service portion of the New Mexico medical assistance
				  programs.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 301 - MEDICAID GENERAL BENEFIT DESCRIPTION › Part 6 - CLIENT MEDICAL TRANSPORTATION SERVICES › Section 8.301.6.8 - MISSION STATEMENT

Current through Register Vol. 35, No. 13, July 16, 2024
To reduce the impact of poverty on the people living in New
				  Mexico and to assure low income and individuals with disabilities in New Mexico
				  equal participation in the life of their communities.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 301 - MEDICAID GENERAL BENEFIT DESCRIPTION › Part 6 - CLIENT MEDICAL TRANSPORTATION SERVICES › Section 8.301.6.9 - CLIENT MEDICAL TRANSPORTATION SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
The medical assistance division (MAD) covers expenses for
				  transportation, meals and lodging it determines are necessary to secure MAD
				  covered medical examination and treatment for eligible recipients in or out of
				  their home community 42 CFR
				  440.170. Travel expenses include the cost of
				  transportation by long distance common carrier, taxicab, handivan, and ground
				  or air ambulance, all as appropriate to the situation and location of the
				  eligible recipient. When medically necessary, MAD covers similar expenses for
				  an attendant who accompanies the eligible recipient to the medical examination
				  or treatment.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 301 - MEDICAID GENERAL BENEFIT DESCRIPTION › Part 6 - CLIENT MEDICAL TRANSPORTATION SERVICES › Section 8.301.6.10 - COVERED SERVICES AND SERVICE LIMITATIONS

Current through Register Vol. 35, No. 13, July 16, 2024
MAD reimburses eligible recipients or transportation
				  providers for medically necessary transportation subject to the
				  following:
A. Free alternatives:
				Alternative transportation services which may be provided free of charge,
				include volunteers, relatives or transportation services provided by nursing
				facilities or other residential centers. An eligible recipient must certify in
				writing that they do not have access to free alternatives.
B. Least costly alternatives: MAD covers the
				most appropriate and least costly transportation alternatives suitable for the
				eligible recipient's medical condition. If an eligible recipient can use
				private vehicles or public transportation, those alternatives must be used
				before the eligible recipient can use more expensive transportation
				alternatives.
C. Non-emergency
				transportation service: MAD covers non-emergency transportation services for an
				eligible recipient who does not have primary transportation and who is unable
				to access a less costly form of public transportation.
D. Long distance common carriers: MAD covers
				long distance services furnished by a common carrier if the eligible recipient
				must leave their home community to receive medical services. Authorization
				forms for direct payment to long distance bus common carriers by MAD are
				available through the eligible recipient's local county income support division
				(ISD) office.
E. Ground ambulance
				services: MAD covers services provided by ground ambulances when:
(1) an emergency which requires ambulance
				service is certified by a physician or is documented in the provider's records
				as meeting emergency medical necessity as defined as:
(a) an emergency condition that 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; and
(b) "medical necessity" for ambulance
				services is established if the eligible recipient's condition is such that the
				use of any other method of transportation is contraindicated and would endanger
				the eligible recipient's health;
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 301 - MEDICAID GENERAL BENEFIT DESCRIPTION › Part 6 - CLIENT MEDICAL TRANSPORTATION SERVICES › Section 8.301.6.11 - NONCOVERED SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
Transportation services are subject to the same limitations
				  and coverage restrictions which exist for other services. A payment for
				  transportation to a MAD non-covered service is subject to retroactive
				  recoupment. MAD does not cover the following services or related costs of
				  travel:
A. attendants where there is
				not required certification from the eligible recipient's medical
				provider;
B. minor aged children of
				the eligible recipient that are simply accompanying the eligible recipient to
				medical services;
C. transportation
				to a non-covered MAD service;
D.
				transportation to a pharmacy provider. See Subsection F of 8.324.14.18 NMAC,
transportation services.
See 8.301.3 NMAC,
General
				Noncovered Services
.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 301 - MEDICAID GENERAL BENEFIT DESCRIPTION › Part 6 - CLIENT MEDICAL TRANSPORTATION SERVICES › Section 8.301.6.12 - OUT-OF-STATE TRANSPORTATION AND RELATED EXPENSES

Current through Register Vol. 35, No. 13, July 16, 2024
All out-of-state transportation, meals and lodging must be
				  prior approved by MAD. Out-of-state transportation is approved only if the
				  out-ofstate medical service is approved. Documentation must be available to the
				  reviewer to justify the out-of-state travel and verify that treatment is not
				  available in the state of New Mexico.
A. Requests for out-of-state transportation
				must be coordinated through the MAD client services bureau or MAD's designated
				contractor.
B. Authorization for
				lodging and meal services by out-of-state providers can be granted for up to 30
				calendar days by MAD. Re-evaluation authorizations are completed prior to
				expiration and every 30 days, thereafter.
C. Transportation to border cities, those
				cities within 100 miles of the New Mexico border (Mexico excluded), are treated
				as in-state provider service. An eligible recipient who receives MAD
				reimbursable services from a border area provider is eligible for
				transportation services to that provider. See 8.302.4 NMAC,
Out of
				State and Border Area Providers,
to determine when a provider is
				considered an out-of-state provider or a border area provider.