New Mexico Administrative Code

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.

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.

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 …

New Mexico Health Care Authority.

The HCA shall establish policies protecting a recipient's rights regarding HIPAA privacy practices 45CFR 164.520. A. Notice of privacy practices requirements: (1) HCA shall provide notice of privacy practices, update the notice as necessary, and distribute the notice and any revi…

HCA shall establish policies protecting a recipient's rights regarding HIPAA privacy practices. A. Alternate means of communication: A recipient or their personal representative shall have the right to request an alternate means of communication and an alternative address to rece…

PHI shall be used or disclosed only by authorized HCC staff or contractors and only in accordance with HCC policies and procedures 45 CFR 164.502(a) and 45 CFR 164.530(i). A. Making a disclosure when an authorization is required: When PHI is requested, an authorized HCC employee …

When a disclosure is made as a result of an exception to an authorization being required, the authorized HCC employee shall follow the specific procedure established for that exception 45CFR 164.502(b), 45 CFR 164.508, 45 CFR 164.512, 45 CFR 164.532. A. Treatment, payment, or hea…

A. Before a disclosure is made for research purposes, a valid authorization must be signed by the recipient or a waiver of authorization must have been obtained from a properly constituted institutional review board (IRB), a privacy board or representation that the PHI is necessa…

The HCC shall record all valid authorizations and record all disclosures of PHI. A. Recording of authorizations: All valid authorizations shall be recorded when received in the PSO's database 45CFR 164.508(b)(6). Any disclosures of PHI shall be made and recorded only by authorize…

The HCC shall apply minimum necessary criteria to limit PHI for the use, disclosure, or request for PHI to the amount necessary to accomplish the task, except for disclosures to or requests by a health care provider for treatment purposes. The minimum necessary criteria do not ap…

The HCC may de-identify PHI on recipients by removing all recipient identifiable information 45CFR 164.514(a)(b). Authorized HCC employees shall forward the PHI to be deidentified to a person with appropriate knowledge of and experience with generally accepted statistical and sci…

A. Termination requirements: Restrictions on the uses and disclosures of PHI shall be terminated if:(1) the recipient or the recipient's personal representative requests the termination in writing; (2) the PSO informs the recipient or the recipient's personal representative in wr…

The HCC shall have privacy protections in all contracts if the contract anticipates that HCC will make disclosures of PHI to the contractor so that the contractor may use the PHI to perform a business associate function on behalf of MAD relating to TPO. The written protections sh…

The rule applies to the general public.

A. HCC workforce: To the extent practicable, the HCC shall mitigate any harmful effect that is known to the HCC from an improper use or disclosure of a recipient's PHI by an HCC employee by applying the requirements set forth in the HCA HIPAA privacy policies and procedures appli…

If the identity or authority of a requestor of PHI is unknown, the identity and authority of that requestor shall be verified prior to any disclosure 45CFR 164.514(h). A. Identification: Upon receipt of a request for PHI, an authorized HCC employee must determine whether the requ…

PHI shall be confidential and shall be subject to safeguarding procedures. PHI shall be restricted from the public 45CFR 164.530(c). A. Restricting access to PHI: When meeting with recipients or their personal representative, HCC employees shall ensure that any PHI that does not …

All members of the HCC workforce shall be trained within appropriate timeframes on HIPAA privacy policies and procedures regarding the proper use and disclosure of PHI 45CFR 164.530(b). A. Initial training: The HCC shall: (1) develop a training plan with HCC supervisory staff inv…

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). Sectio…

Permanent.

July 1, 2024, unless a later date is cited at the end of a section.

The objective of this rule is to provide Health Insurance Portability and Accountability Act (HIPAA) instructions and policies for the New Mexico medical assistance programs.

The following definitions apply to terms used in this chapter. A. Alternate address: A location other than the primary address on file with HCA for the recipient or the recipient's personal representative. B. Alternate means of communication: A communication made other than in wr…

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.

This part describes HIPAA policies including health plan responsibilities, disclosure requirements, minimum necessary, business associates, sanctions, reporting, and documentation requirements. The HCC shall meet all requirements in this chapter. A. Medicaid is a health plan and …

New Mexico Health Care Authority.

The rule applies to the general public.

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 …

Permanent.

July 1, 2024, unless a later date is cited at the end of a section.

The objective of these rules is to provide instruction for the service portion of the New Mexico medical assistance programs.

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.

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 i…

New Mexico Health Care Authority.

A. Health care to New Mexico MAD eligible recipients is furnished by a variety of providers and provider groups. The reimbursement for these services is administered by MAD. Upon approval of a New Mexico MAD provider participation agreement or a MAD EHR incentive payment agreemen…

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…

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 desc…

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 …

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 pur…

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 eli…

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 …

The rule applies to the general public.