reglab/statecodes huggingface dataset:
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 10 - BRAIN INJURY SERVICES FUND PROGRAM › Section 8.326.10.13 - BRAIN INJURY SERVICES FUND HOME AND COMMUNITY-BASED SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
BISF home and community-based services (HCBS) and goods are
				  for outpatient care administered within the state of New Mexico and must
				  address the participant's assessed needs and include the expectation of
				  individual and family participation. BISF HCBS are designed to resolve a
				  participant's identified crisis, enhance the individual's self-determination
				  and promote independence. BISF HCBS funding can only be used for services and
				  goods that are documented in the participant's ILP and or substantiated by
				  physician's orders or other required documentation, as appropriate. As the
				  payer of last resort, BISF funding may be used for the purchase of authorized
				  services or goods that are not covered by medicaid, medicare, the special
				  education-individuals with disability education act (IDEA) program, department
				  of vocational rehabilitation (DVR), private insurance or other responsible
				  payer sources. The delivery of all BISF HCBS will be in accordance with the
				  standards set by HSD.
A.
BISF
				HCBS eligibility requirements:
BISF HCBS can only be provided to program
				participants who have a current BISF service coordinator and have met BISF
				program requirements. Eligibility for BISF HCBS is based upon the service
				coordinator's assessment of participant needs, verification that no responsible
				payer source exists, and receipt of supporting medical documentation, as
				appropriate to justify the need for a requested service or good. Referrals for
				qualifying participants are submitted to the FIA, who arranges and pays for
				authorized goods and services in 90-day increments.
B.
Funding limits per
				participant:
There is a maximum yearly and lifetime coverage for
				eligible participants as determined by their assessed needs. Funding is also
				limited by legislative or departmental appropriation. Coverage limitations for
				qualifying participants are as follows:
(1)
				No more than the annual budgetary cap per participant as prescribed by HSD,
				unless through approved written exception by HSD; this value represents a
				maximum amount that may be budgeted and is not a guaranteed annual budget
				assignment.
(2) $75,000 lifetime
				maximum for combined services and goods;
(3) $10,000 lifetime limit on environmental
				modifications; and
(4) only one
				emergency housing assistance per participant in a lifetime, unless an exception
				is made in writing by the BISF program manager at the HSD.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 10 - BRAIN INJURY SERVICES FUND PROGRAM › Section 8.326.10.14 - NON-COVERED SERVICES AND GOODS

Current through Register Vol. 35, No. 13, July 16, 2024
Costs not covered by BISF HCBS include:
A. Dental exams, visits, procedures or
				equipment;
B. Optical exams,
				visits, glasses, lenses or other equipment;
C. Hearing exams, visits or aids or other
				equipment;
D. Experimental
				therapies;
E. Computers and
				internet;
F. Cell phones or cell
				phone carrier service;
G.
				Organizational supplies;
H. Service
				animals, certification or training of service animals, veterinary, grooming,
				boarding or maintenance costs;
I.
				Health insurance deductibles or premiums; and
J. Institutional care, nursing facility or
				hospital care costs.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 10 - BRAIN INJURY SERVICES FUND PROGRAM › Section 8.326.10.15 - SERVICE AUTHORIZATION AND REIMBURSEMENT

Current through Register Vol. 35, No. 13, July 16, 2024
Funding for BISF service coordination, BISF HCBS and fiscal
				  intermediary agent services is based upon trust fund revenues and legislative
				  or departmental appropriation. Billings and receiptsfor all approved goods,
				  services and supports, shall be submitted for payment or reimbursement within
				  90 days of the service date, by the participant, service coordinator or vendor,
				  following all HSD BISF program instructions. Reimbursement for goods, services
				  and supports are made at a predetermined reimbursement rate. The HSD reserves
				  the right to approve or disapprove any and all vendors or subcontractors used
				  by the BISF HCBS fiscal intermediary agent.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 326 - CASE MANAGEMENT SERVICES › Part 10 - BRAIN INJURY SERVICES FUND PROGRAM › Section 8.326.10.16 - GRIEVANCE AND APPEALS PROCESSES FOR THE BRAIN INJURY SERVICES FUND PROGRAM

Current through Register Vol. 35, No. 13, July 16, 2024
The BISF program allows for a grievance or complaint process
				  that affords program participants the opportunity to register grievances or
				  complaints concerning the provision of services that are administered through
				  the BISF program.
A.
Grievances:
(1) Program
				participants may register complaints with the service coordination and FIA
				contractors.
(2) Individual BISF
				contractors will have written grievance procedures approved by HSD, which
				provide the participant or their representative with a process for expressing
				dissatisfaction with the program services.
(3) The contractor's written grievance
				procedure is to be available upon request by program participants, HSD or its
				assigns.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 349 - COORDINATED SERVICE CONTRACTORS › Part 2 - APPEALS AND GRIEVANCE PROCESS › Section 8.349.2.3 - 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 349 - COORDINATED SERVICE CONTRACTORS › Part 2 - APPEALS AND GRIEVANCE PROCESS › Section 8.349.2.5 - 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 349 - COORDINATED SERVICE CONTRACTORS › Part 2 - APPEALS AND GRIEVANCE PROCESS › Section 8.349.2.6 - 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 349 - COORDINATED SERVICE CONTRACTORS › Part 2 - APPEALS AND GRIEVANCE PROCESS › Section 8.349.2.8 - 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 349 - COORDINATED SERVICE CONTRACTORS › Part 2 - APPEALS AND GRIEVANCE PROCESS › Section 8.349.2.9 - COORDINATED SERVICE CONTRACTORS (CSC)

Current through Register Vol. 35, No. 13, July 16, 2024
CSCs that manage some services of the medicaid program are
				  responsible for any or all aspects of program management, prior authorization,
				  utilization review, claims processing, and issuance of remittance advices and
				  payments.
A. The CSC shall have a
				grievance system in place for recipients that include a grievance process
				related to dissatisfaction and an appeals process related to a CSC's action,
				including the opportunity to request an HCA fair hearing.
B. A grievance is a recipient's expression of
				dissatisfaction about any matter or aspect of the CSC or its operation, other
				than a CSC's action, as defined below.
C. An appeal is a request for review by the
				CSC of a CSC's action. An action is the denial or limited authorization of a
				requested service, including the type or level of service; the reduction,
				suspension, or termination of a previously authorized service; the denial, in
				whole or in part, of payment for a service; or the failure to provide services
				in a timely manner. An untimely service authorization constitutes a denial and
				is thus considered an action.
D.
				The recipient, legal guardian of the recipient for a minor or an incapacitated
				adult, or a representative of the recipient as designated in writing to the
				CSC, has the right to file a grievance or an appeal of the CSC's action on
				behalf of the recipient. A provider acting on behalf of the recipient, with the
				recipient's written consent, may file a grievance or an appeal of a CSC's
				action.
E. In addition to the CSC's
				grievance and appeal process described above, a recipient, legal guardian of
				the recipient for a minor or an incapacitated adult, or the representative of
				the recipient has the right to request a fair hearing on behalf of the
				recipient with HCA directly as described in 8.352.2 NMAC,
Recipient
				Hearings
, if a CSC's decision results in termination, modification,
				suspension, reduction, or denial of services to the recipient or if the
				recipient believes the CSC has taken an action erroneously. A fair hearing may
				be requested prior to, concurrent with, subsequent to, or in lieu of a
				grievance or appeal to the CSC.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 349 - COORDINATED SERVICE CONTRACTORS › Part 2 - APPEALS AND GRIEVANCE PROCESS › Section 8.349.2.10 - GENERAL REQUIREMENTS FOR GRIEVANCE AND APPEALS

Current through Register Vol. 35, No. 13, July 16, 2024
A. The CSC shall implement written policies
				and procedures describing how the recipient may submit a request for a
				grievance or an appeal with the CSC or submit a request for a fair hearing with
				the HCA. The policy shall include a description of how the CSC resolves the
				grievance or appeal.
B. The CSC
				shall provide to all service providers and subcontractors in the CSC's network
				a written description of the CSC's grievance and appeal process and how the
				provider can submit a grievance or appeal.
C. The CSC shall have available reasonable
				assistance in completing forms and taking other procedural steps. This
				includes, but is not limited to, providing interpreter services and toll-free
				numbers that have adequate TTY/TTD and interpreter capability.
D. The CSC shall name a specific
				individual(s) designated as the CSC's medicaid recipient grievance coordinator
				with the HCA to administer the policies and procedures for resolution of a
				grievance or an appeal, to review patterns/trends in grievances or appeals, and
				to initiate corrective action.
E.
				The CSC shall ensure that the individuals that make the decisions on grievances
				or appeals are not involved in any previous level of review or decision-making.
				The CSC shall also ensure that health care professionals with appropriate
				clinical expertise shall make decisions for the following:
(1) an appeal of a CSC denial that is based
				on lack of medical necessity;
(2) a
				CSC denial that is upheld in an expedited resolution;
(3) a grievance or appeal that involves
				clinical issues.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 349 - COORDINATED SERVICE CONTRACTORS › Part 2 - APPEALS AND GRIEVANCE PROCESS › Section 8.349.2.11 - GRIEVANCE

Current through Register Vol. 35, No. 13, July 16, 2024
A grievance is a recipient's expression of dissatisfaction
				  about any matter or aspect of the CSC or its operation.
A. A recipient may file a grievance either
				orally or in writing with the CSC within 90 calendar days of the date the event
				causing the dissatisfaction occurred. The legal guardian of the recipient for a
				minor or an incapacitated adult, a representative of the recipient as
				designated in writing to the CSC, and a provider acting on behalf of the
				recipient and with the recipient's written consent, have the right to file a
				grievance on behalf of the recipient.
B. Within five working days of receipt of the
				grievance, the CSC shall provide the grievant with written notice that the
				grievance has been received and the expected date of its resolution.
C. The investigation and final CSC resolution
				process for grievances shall be completed within 30 calendar days of the date
				the grievance is received by the CSC and shall include a resolution letter to
				the grievant or the grievant' s representative.
D. The CSC may request an extension from HCA
				up to 14 calendar days if the grievant requests the extension, or the CSC
				demonstrates to HCA that there is need for additional information, and the
				extension is in the recipient's interest. For any extension not requested by
				the grievant, the CSC shall give the grievant written notice of the reason for
				the extension within two working days of the decision to extend the
				timeframe.
E. Upon resolution of
				the grievance, the CSC shall mail a resolution letter to the grievant, legal
				guardian, representative, and provider acting on behalf of the recipient. The
				resolution letter shall include, but not be limited to, the following:
(1) all information considered in
				investigating the grievance;
(2)
				findings and conclusions based on the investigation; and
(3) the disposition of the
				grievance.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 349 - COORDINATED SERVICE CONTRACTORS › Part 2 - APPEALS AND GRIEVANCE PROCESS › Section 8.349.2.12 - APPEALS

Current through Register Vol. 35, No. 13, July 16, 2024
An appeal is a request for review by the CSC of a CSC
				  action.
A. An action is defined as:
(1) the denial or limited authorization of a
				requested service, including the type of level of service;
(2) the reduction, suspension, or termination
				of a previously authorized service;
(3) the denial, in whole or in part, of
				payment for a service;
(4) the
				failure of the CSC to provide services in a timely manner, as defined by HCA;
				or
(5) the failure of the CSC to
				complete the authorization request in a timely manner as defined in
				42 CFR
				438.408.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 349 - COORDINATED SERVICE CONTRACTORS › Part 2 - APPEALS AND GRIEVANCE PROCESS › Section 8.349.2.13 - EXPEDITED RESOLUTION OF APPEALS

Current through Register Vol. 35, No. 13, July 16, 2024
An expedited resolution of an appeal is an expedited review
				  by the CSC of a CSC action.
A. The CSC
				shall establish and maintain an expedited review process for appeals when the
				CSC determines that allowing the time for a standard resolution could seriously
				jeopardize the recipient's life or health or ability to attain, maintain, or
				regain maximum function. Such a determination is based on:
(1) a request from the recipient;
(2) a provider's support of the recipient's
				request;
(3) a provider's request
				on behalf of the recipient; or
(4)
				the CSC's independent determination.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 349 - COORDINATED SERVICE CONTRACTORS › Part 2 - APPEALS AND GRIEVANCE PROCESS › Section 8.349.2.14 - SPECIAL RULE FOR CERTAIN EXPEDITED SERVICE AUTHORIZATION DECISIONS

Current through Register Vol. 35, No. 13, July 16, 2024
In the case of expedited service authorization decisions that
				  deny or limit services, the CSC shall, within 72 hours of receipt of the
				  request for service, automatically file an appeal on behalf of the recipient,
				  use its best effort, to give the recipient oral notice of the decision on the
				  automatic appeal and to resolve the appeal.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 349 - COORDINATED SERVICE CONTRACTORS › Part 2 - APPEALS AND GRIEVANCE PROCESS › Section 8.349.2.15 - OTHER RELATED COORDINATED SERVICE CONTRACTOR (CSC) PROCESSES

Current through Register Vol. 35, No. 13, July 16, 2024
A. Information
				about grievance system to providers and subcontractors: The CSC shall provide
				information specified in 42
				CFR 438.10(g) (1) about the
				grievance system to all providers and subcontractors at the time that they
				enter into a contract.
B. Grievance
				or appeal files:
(1) All grievance or appeal
				files shall be maintained in a secure and designated area and accessible to
				HCA, upon request, for review. Grievance or appeal files shall be retained for
				six years following the final decision by the CSC, HCA, and administrative law
				judge, judicial appeal, or closure of a file, whichever occurs later.
(2) The CSC shall have procedures for
				assuring that files contain sufficient information to identify the grievance or
				appeal, the date it was received, the nature of the grievance or appeal, notice
				to the recipient of receipt of the grievance or appeal, all correspondence
				between the CSC and the recipient, the date the grievance or appeal is
				resolved, the resolution, the notices of final decision to the recipient, and
				all other pertinent information.
(3) Documentation regarding the grievance
				shall be made available to the grievant, legal guardian representative, or
				provider acting on behalf of the recipient if requested.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 349 - COORDINATED SERVICE CONTRACTORS › Part 2 - APPEALS AND GRIEVANCE PROCESS › Section 8.349.2.16 - COORDINATED SERVICE CONTRACTOR (CSC) PROVIDER GRIEVANCE PROCESS

Current through Register Vol. 35, No. 13, July 16, 2024
The CSC shall establish and maintain written policies and
				  procedures for the filing of provider grievances. A provider shall have the
				  right to file a grievance with the CSC regarding utilization management
				  decisions or provider payment issues. Grievances shall be resolved within 30
				  calendar days. A provider may not file a grievance on behalf of a recipient
				  without written designation by the recipient as the recipient's representative.
				  See 8.349.2.14 NMAC for special rules
				  for certain expedited service authorizations.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 350 - RECONSIDERATION OF UTILIZATION REVIEW › Part 2 - RECONSIDERATION OF UTILIZATION REVIEW DECISIONS › Section 8.350.2.3 - 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 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 350 - RECONSIDERATION OF UTILIZATION REVIEW › Part 2 - RECONSIDERATION OF UTILIZATION REVIEW DECISIONS › Section 8.350.2.5 - EFFECTIVE DATE

Current through Register Vol. 35, No. 13, July 16, 2024
August 1, 2014 unless a later date is cited at the end of a
				  section.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 350 - RECONSIDERATION OF UTILIZATION REVIEW › Part 2 - RECONSIDERATION OF UTILIZATION REVIEW DECISIONS › Section 8.350.2.6 - 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 medicaid programs.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 350 - RECONSIDERATION OF UTILIZATION REVIEW › Part 2 - RECONSIDERATION OF UTILIZATION REVIEW DECISIONS › Section 8.350.2.8 - 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 350 - RECONSIDERATION OF UTILIZATION REVIEW › Part 2 - RECONSIDERATION OF UTILIZATION REVIEW DECISIONS › Section 8.350.2.9 - UTILIZATION REVIEW DECISIONS

Current through Register Vol. 35, No. 13, July 16, 2024
A.
				Utilization review (UR) decisions are those decisions the medical assistance
				division (MAD), its utilization review (UR) contractor or a MAD designee makes
				regarding the medical necessity of services or items that require authorization
				for medical necessity or a level of care (LOC) determination prior to
				reimbursement by MAD and its fee-for-service program. For applicable rules for
				services and items provided through a MAD managed care organization (MCO),
				refer to 8.308.15 NMAC. For applicable rules for services and items provided
				through coordinated service contractors, refer to 8.349.2 NMAC.
B. For services for which payment has already
				been made for which MAD is recouping payment due to a post payment review of
				medical necessity or LOC, the applicable rule is 8.532.3 NMAC.
C. Decisions are based on information
				submitted by the provider in a format specified by MAD, its UR contractor, or a
				MAD designee, and applicable New Mexico Administrative Code (NMAC) MAD
				rules.
D. Prior to making a
				decision, MAD, its UR contractor or a MAD designee may issue a request for
				information (RFI) to the provider requesting clarification or additional
				information in order to have sufficient information to render an appropriate
				decision. The provider must submit the clarification or additional information
				within 21 calendar days of issuance of the request or a technical denial may be
				issued.
E. MAD, its UR contractor
				or a MAD designee may deny or reduce the authorized services or items in
				frequency, intensity, duration, quantity, scope or level of care after
				considering the submitted documentation or NMAC MAD rules. An eligible provider
				or eligible recipient who is dissatisfied with the decision may proceed as
				detailed in Section 10 of this rule.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 350 - RECONSIDERATION OF UTILIZATION REVIEW › Part 2 - RECONSIDERATION OF UTILIZATION REVIEW DECISIONS › Section 8.350.2.10 - RECONSIDERATION OF UTILIZATION REVIEW DECISIONS

Current through Register Vol. 35, No. 13, July 16, 2024
A provider who is dissatisfied with a medical necessity or
				  LOC decision by MAD, its UR contractor or a MAD designee, can request
				  reconsideration. An eligible recipient who is dissatisfied with a medical
				  necessity or LOC decision by MAD, its UR contractor or a MAD designee, can
				  request the provider to pursue reconsideration on his or her behalf.
A.
Time constraints and submission
				requirements:
Requests for reconsideration must be in writing and
				received by MAD, its UR contractor or a MAD designee within 30 calendar days
				after the date on the initial notice of action.
B.
Requirement for filing an
				extension:
MAD, its UR contractor or a MAD designee will accept a
				request for reconsideration filed up to 14 calendar days past the 30 calendar
				day limit if MAD finds that there was good cause for the provider's or the
				eligible recipient's failure to file a timely request. The provider or the
				eligible recipient must furnish written documentation of good cause. Good cause
				includes a death in the family, a disabling personal illness or another
				significant emergency or other exceptional circumstance.
C.
Information required in the request
				for reconsideration:
The request for reconsideration must include the
				following:
(1) reference to the challenged
				decision or action;
(2) basis for
				the challenge;
(3) copies of any
				document(s) pertinent to the challenged decision or action;
(4) copies of claim form(s) if the challenge
				involves a claim for payment which is denied due to an UR decision;
				and
(5) a statement that a
				reconsideration of the decision is requested.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 350 - RECONSIDERATION OF UTILIZATION REVIEW › Part 2 - RECONSIDERATION OF UTILIZATION REVIEW DECISIONS › Section 8.350.2.11 - CLAIMANT HEARINGS

Current through Register Vol. 35, No. 13, July 16, 2024
MAD has established a process to determine if an individual
				  is eligible to request a HSD administrative hearing. MAD has also established a
				  process for an individual or the individual's authorized representative to
				  request an HSD administrative hearing when an UR reconsideration decision
				  results in an adverse action that is intended or has been taken by MAD, its UR
				  contractor or a MAD designee. See 8.352.2 NMAC for the definition of an
				  authorized representative. MAD must grant an individual or his or her
				  authorized representative the opportunity for a HSD administrative hearing
				  under specific circumstances pursuant to
				  42 CFR Section
				  431.220(a) and Section
				  27-3-3 NMSA 1978. A request for a HSD administrative hearing must be received
				  within 30 days of the date of its UR reconsideration decision. A HSD
				  administrative hearing occurs telephonically between the parties to the hearing
				  and the assigned ALJ. See 8.352.2 NMAC for detailed description of a HSD
				  administrative claimant hearing process. At the time the eligible recipient or
				  his or her authorized representative requests a HSD administrative hearing, the
				  eligible recipient is referred to as the claimant.
A.
Record preservation:
To
				preserve a record for review, MAD, its UR contractor or a MAD designee
				documents and retains a record of the reconsideration determination.
B.
Documentation requirements:
The record preserved by MAD, its UR contractor or a MAD designee includes all
				documentation of the initial UR decision, copies of any documents relevant to
				the initial decision, any additional evidence presented during the
				reconsideration, and a copy of the reconsideration determination.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 350 - RECONSIDERATION OF UTILIZATION REVIEW › Part 3 - ABSTRACT SUBMISSION FOR LEVEL OF CARE DETERMINATIONS › Section 8.350.3.3 - 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 350 - RECONSIDERATION OF UTILIZATION REVIEW › Part 3 - ABSTRACT SUBMISSION FOR LEVEL OF CARE DETERMINATIONS › Section 8.350.3.6 - 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 350 - RECONSIDERATION OF UTILIZATION REVIEW › Part 3 - ABSTRACT SUBMISSION FOR LEVEL OF CARE DETERMINATIONS › Section 8.350.3.8 - 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 350 - RECONSIDERATION OF UTILIZATION REVIEW › Part 3 - ABSTRACT SUBMISSION FOR LEVEL OF CARE DETERMINATIONS › Section 8.350.3.9 - ABSTRACT SUBMISSION FOR LEVEL OF CARE DETERMINATIONS

Current through Register Vol. 35, No. 13, July 16, 2024
The medical assistance division (MAD) utilization review (UR)
				  contractor performs prior approval and abstract review on admissions,
				  readmissions, and continued stay requests for all long-term care nursing
				  facilities (NF) and intermediate care facilities for the mentally retarded
				  (ICF-MR). Within ten (10) working days after a recipient's admission to a
				  nursing facility or intermediate care facility for the mentally retarded
				  (ICF-MR), the facility must submit a long-term care abstract to the UR
				  contractor for review. The initial admission abstract describes the recipient's
				  functional level and level of care needs and includes the physician's history
				  and physical examination and preadmission screening and annual resident review
				  (PASARR). Readmissions and continued-stay request abstracts must be submitted
				  to the UR contractor ten (10) working days before the expiration of the
				  currently certified length of stay.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 350 - RECONSIDERATION OF UTILIZATION REVIEW › Part 3 - ABSTRACT SUBMISSION FOR LEVEL OF CARE DETERMINATIONS › Section 8.350.3.10 - REQUESTS FOR RETROACTIVE PRIOR APPROVAL REVIEW

Current through Register Vol. 35, No. 13, July 16, 2024
MAD permits facilities to request retroactive prior approval
				  review of long-term care abstracts which are not submitted for level-of-care
				  reviews within the applicable time period if certain conditions are met.
A.
Initial abstracts:
Facilities
				must submit a request for retroactive prior approval review when delays in the
				submission of an initial abstract beyond the ten (10) working day period are
				caused by circumstances beyond the facility's control, including:
(1) physician does not sign orders or history
				and physical within the time period; or
(2) medicaid eligibility decisions have not
				been completed.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 350 - RECONSIDERATION OF UTILIZATION REVIEW › Part 3 - ABSTRACT SUBMISSION FOR LEVEL OF CARE DETERMINATIONS › Section 8.350.3.11 - SUBMITTING ABSTRACTS FOR RETROACTIVE PRIOR APPROVAL REVIEW

Current through Register Vol. 35, No. 13, July 16, 2024
A. To request
				retroactive prior approval review, a facility must submit the abstract, a
				request for retroactive prior approval review form and supporting documentation
				to the UR contractor. Facilities must provide at least the following supporting
				documentation:
(1) pertinent information,
				such as physician orders, history and physical, physician progress notes or
				hospital discharge summaries; all documentation must be date-stamped by the
				facility verifying date of receipt from the physician or hospital.
(2) dated facility entries and records that
				document telephone calls to physicians reminding them of the need to complete
				the abstract, physician orders, history and physical or progress
				notes;
(3) date-stamped copy of the
				notification of medicaid eligibility; and
(4) documentation of other reasons for
				delay.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 350 - RECONSIDERATION OF UTILIZATION REVIEW › Part 3 - ABSTRACT SUBMISSION FOR LEVEL OF CARE DETERMINATIONS › Section 8.350.3.12 - REVIEW OF RETROACTIVE PRIOR APPROVAL REVIEW DENIALS

Current through Register Vol. 35, No. 13, July 16, 2024
Providers who disagree with abstract review decisions or
				  denials of retroactive prior approval review can request a re-review and
				  reconsideration. See Section MAD-953,
Reconsideration of Utilization
				  Review Decisions
for specific information on the review
				  process.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 350 - RECONSIDERATION OF UTILIZATION REVIEW › Part 3 - ABSTRACT SUBMISSION FOR LEVEL OF CARE DETERMINATIONS › Section 8.350.3.13 - PAYMENT FOLLOWING APPROVAL OF RETROACTIVE PRIOR APPROVAL REVIEW ABSTRACTS

Current through Register Vol. 35, No. 13, July 16, 2024
Medicaid reimburses facilities in the following manner after
				  approval of a retroactive prior approval review:
A. for late initial abstracts caused by
				delayed physician signature, reimbursement is effective back to the date of
				admission;
B. for late initial
				abstracts caused by delayed medicaid eligibility decisions, reimbursement is
				effective back to the date the recipient became medicaid-eligible;
C. for late continued-stay abstracts caused
				by delays in obtaining physician signature or retroactive medicaid eligibility,
				reimbursement is effective from the beginning of the certification period for
				continued stay;
D. for the first
				ten (10) late abstracts per facility per calendar when delay is attributed to
				circumstances within the facility's control, reimbursement is effective back to
				the date of admission or the beginning of the certification period for
				continued stay applicable to the situation; and
E. for late abstracts beyond the ten (10)
				allowed by medicaid attributed to circumstances within the facility's control,
				the earliest possible effective date is the date the late abstract was received
				by the UR contractor.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 350 - RECONSIDERATION OF UTILIZATION REVIEW › Part 4 - RECONSIDERATION OF AUDIT SETTLEMENTS › Section 8.350.4.3 - 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 NMSA 1978 Section 27-2-12 et.
				  seq. (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 350 - RECONSIDERATION OF UTILIZATION REVIEW › Part 4 - RECONSIDERATION OF AUDIT SETTLEMENTS › Section 8.350.4.6 - 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 350 - RECONSIDERATION OF UTILIZATION REVIEW › Part 4 - RECONSIDERATION OF AUDIT SETTLEMENTS › Section 8.350.4.8 - 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 350 - RECONSIDERATION OF UTILIZATION REVIEW › Part 4 - RECONSIDERATION OF AUDIT SETTLEMENTS › Section 8.350.4.9 - RECONSIDERATION OF AUDIT SETTLEMENTS

Current through Register Vol. 35, No. 13, July 16, 2024
A.
General Reconsideration Process:
Medicaid providers who disagree
				with an audit settlement can submit a written request for a reconsideration to
				the New Mexico Medical Assistance Division (MAD) within thirty (30) calendar
				days of the date on the notice of final settlement. The written request may be
				submitted by facsimile or by U.S. mail but not by electronic mail. The written
				request must be received by MAD no later than the thirtieth day from the date
				of the notice. Filing of a request for reconsideration does not affect the
				imposition of the final settlement.
(1)
Information Included in the Request:
The written request for
				reconsideration must identify each point on which the provider takes an issue
				with the audit agent and include all documentation, citations of authority, and
				arguments on which the request is based. Any point or issue not raised in the
				original request for reconsideration may not be raised later and will not be
				considered in the final decision of the reconsideration.
(2)
Audit Agent Response:
The
				written request and supporting materials is forwarded to the audit agent for
				reconsideration. The audit agent must file a response with MAD within thirty
				(30) calendar days of the receipt of the request and supporting material from
				MAD.
(3)
Submission of
				Additional Material:
MAD forwards the audit agent's response to the
				provider. Additional material from the audit agent or the provider must be
				received by MAD within fifteen (15) calendar days of the date the response was
				forwarded to the provider. Any additional information, the request for
				reconsideration and supporting documentation, and the audit agent's response
				constitute final submittal. The packet containing the final submittal is
				provided to the MAD Deputy Director for final submittal by the responsible
				bureau for program reimbursement.
(4)
Decision by MAD:
The Deputy
				Director may call on all information and call on all expertise he/she believes
				is necessary to decide the issue. The Deputy Director makes a determination and
				submits a written copy of his/her findings to each party within forty-five (45)
				calendar days of the date of final submittal to the MAD Director. The decision
				may be sent to the parties by facsimile or U.S. mail. The provider may appeal
				an adverse decision on the request for reconsideration to the New Mexico Human
				Services Department's Hearings Bureau pursuant to the 8.353.10 NMAC. The MAD
				Director or designee shall make the decision on the recommendation from the
				hearing officer.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 351 - SANCTIONS OR REMEDIES › Part 2 - SANCTIONS AND REMEDIES › Section 8.351.2.3 - 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 27-1-12 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 351 - SANCTIONS OR REMEDIES › Part 2 - SANCTIONS AND REMEDIES › Section 8.351.2.6 - 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 programs
				  (MAP).
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 351 - SANCTIONS OR REMEDIES › Part 2 - SANCTIONS AND REMEDIES › Section 8.351.2.8 - 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 351 - SANCTIONS OR REMEDIES › Part 2 - SANCTIONS AND REMEDIES › Section 8.351.2.9 - SANCTIONS AND REMEDIES

Current through Register Vol. 35, No. 13, July 16, 2024
The medical assistance division (MAD) is required to impose
				  sanctions or penalties against providers for fraud, violations of federal or
				  state law, violations of HIPAA regulations, failure to meet professional
				  standards of conduct, non-compliance with the medical assistance division's New
				  Mexico administrative code (NMAC) rules, violations of the Medicaid Provider
				  Act, and other misconduct. See 42 CFR Part 455; Section
				  30-44-3
				  NMSA 1978 (Repl. Pamp. 1998). HSD recovers overpayments made to MAD enrolled
				  providers, to include HSD contracted managed care organizations (MCO)
				  contracted providers; and to a MCO's out-of-network providers who have billed
				  and received payments from a HSD contracted MCO. For applying sanctions and
				  remedies, any of the following are considered a MAD enrolled provider.
A. Any individual or other entity who has
				signed a provider participation agreement (PPA) with MAD, or who has signed an
				agreement or contract with a HSD contracted MCO.
B. Any individual or other entity who has
				otherwise received payment for treating or providing services to a medical
				assistance program (MAP) eligible recipient as an out-of-network provider, a
				participating or non participating provider, a subcontracted provider, or who
				participates in an entity contracted by HSD or a HSD contracted MCO, including
				but not limited to, pharmacy benefit managers, dental benefit administrators,
				and contracted transportation services.
C. Any individual or other entity that
				provides a service to a MAP eligible recipient which results in a claim for
				payment by MAD, the HSD contracted fiscal agent, or by a HSD contracted MCO or
				coordinated care organization with or without a contractual basis for the claim
				submission.
D. Any individual or
				other entity who submits a claim to medicare or to a medicare advantage plan
				for a MAP eligible recipient, for which a copayment, coinsurance, or deductible
				is applied.
E. An employee, owner,
				or contractor to any of the above.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 351 - SANCTIONS OR REMEDIES › Part 2 - SANCTIONS AND REMEDIES › Section 8.351.2.11 - TYPES OF SANCTIONS

Current through Register Vol. 35, No. 13, July 16, 2024
HSD is allowed to impose monetary or non-monetary sanctions
				  against any provider or other entity for misconduct. HSD is required to impose
				  certain sanctions against a provider or other entity for fraud, HIPAA
				  violations, and other actions. Sanctions may be applied to any provider or
				  other entity receiving payment for services either directly through MAD or
				  through its managed care contractor, subcontractor, or other provider.
A.
Prior approval:
As a
				condition of payment, MAD or a HSD contracted MCO can require a provider to
				obtain prior approval before delivering all or certain services including prior
				to prescribing or ordering services. The prior approval request must be
				submitted to the HSD's contracted MCO or the MAD UR contractor in a manner
				prescribed for general utilization review. Failure to obtain prior approval
				prior to furnishing a service may result in imposition of sanctions. In
				addition, MAD may sanction a provider or other entity by requiring him or her
				to obtain prior approval before furnishing all or certain services, including
				prior to prescribing or ordering services, even if other providers may furnish
				that service without the requirement of obtaining prior approval; see 8.302.5
				NMAC.
B.
Education:
As
				a condition of payment, MAD or a HSD contracted MCO can require a provider or
				other entity to attend an educational program if misconduct could be remedied
				with the provision of identified education. MAD or a HSD contracted MCO may
				also require a provider or other entity who is seeking reinstatement to attend
				a specific educational program prior to the approval of his or her new PPA
				application. Provider education programs may include, but are not limited to,
				the following:
(1) claim form
				completion;
(2) use and format of
				the MAD NMAC rules;
(3) use of
				procedure codes;
(4) substantive
				provisions of MAD's NMAC rule, policy, and requirement;
(5) reimbursement rates;
(6) assistance in claims coding and billing;
				and
(7) continuing medical or
				behavioral health education.
New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 351 - SANCTIONS OR REMEDIES › Part 2 - SANCTIONS AND REMEDIES › Section 8.351.2.12 - IMPOSITION OF SANCTIONS

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Mandatory sanctions:
MAD must impose sanctions when a provider
				receives a formal reprimand or censure for unethical practice by a professional
				association of the provider's peers or when a provider is suspended or
				terminated from participation in medicare or any federal or state-funded health
				care program. Imposition of sanctions are applied to any provider or other
				entity receiving payment for services either directly through MAD, its
				contractor, or through any HSD contracted MCO, subcontractor, or
				provider.
B.
Permissive
				sanctions:
MAD can impose monetary or non-monetary sanctions against a
				provider or other entity for fraud or other forms of misconduct.
C.
Criteria used in assessment of
				permissive sanctions:
MAD uses the following criteria to determine the
				type of permissive or mandatory sanction to impose:
(1) seriousness of the violation;
(2) number and nature of a
				violation;
(3) history of a prior
				violation or prior sanction;
(4)
				action or recommendation of peer review group or licensing board;
(5) nature and degree of adverse impact of
				the sanction upon a MAP eligible recipient;
(6) cost to MAD or a HSD contracted MCO of
				the violation;
(7) mitigating
				circumstances; and
(8) other
				relevant facts.