New Mexico Administrative Code

To comply with Title XIX of the Social Security Act, as amended, MAD is required to serve certain groups of eligible recipients and has the option of paying for services provided to other eligible recipient groups 42 CFR 435.1 . MAD is also required to pay for emergency services …

A hospital, nursing facility, intermediate care facility for individuals with intellectual disabilities, hospice agency and home health agency is required to give an eligible recipient or personal representative information about their right to make their own health decisions, in…

A provider must furnish covered services to an eligible recipient in the same scope, quality and manner as provided to the general public. Within the limits of medical assistance programs, a provider may not discriminate on the basis of race, color, national origin, sex, gender, …

Reimbursement to a provider for services or procedures is based on the MAD reimbursement fee schedule, reimbursement rate, or reimbursement methodology in place at the time the services were furnished by the provider. A provider who furnishes services to an eligible recipient agr…

A provider may only bill an eligible recipient or accept payment for services if all of the following requirements are satisfied: A. The eligible recipient is advised by the provider before services are furnished that a particular service is not covered by MAD or that the particu…

A provider must maintain all the records necessary to fully disclose the nature, quality, amount and medical necessity of services furnished to an eligible recipient who is currently receiving or who has received services in the past. (42 CFR 431.107(b)). Services billed to MAD n…

A provider is required to comply with the HIPAA privacy regulations. Confidential medical information regarding medicaid information on the applicant or eligible recipient must be released by providers to MAD, and to other state or federal agencies, or their employees at no cost …

A provider must furnish MAD with the following information. See 42 CFR 431.107(b) (2)(3): name and address of each person with an ownership or controlling interest in the entity or in any subcontractor in which the entity has a direct or indirect ownership interest totaling five …

The rule applies to the general public.

A. Provider status may be terminated if the provider or MAD gives the other written notice of termination at least 60 calendar days before the effective termination date. (1) Facility provider must also give at least 15 calendar days notice to the public by publishing a statement…

As soon as possible, but at least 60 calendar days after a change in ownership, MAD reserves the right to withhold payment on all pending or current claims until any right MAD has to recoup portions or all of those payments is determined. Payment will not be withheld if MAD recei…

The findings of a MAD survey used to determine the ability of facility provider to begin or continue as medicaid participating provider is available to the public within 90 calendar days of completion. A. Documents subject to disclosure: Documents subject to public disclosure inc…

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 27-2-12 et. seq. NMSA 1978 (Repl. Pamp. 1991). Section 9-8-…

Permanent.

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

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

Medically necessary services A. Medically necessary services are clinical and rehabilitative physical or behavioral health services that: (1) are essential to prevent, diagnose or treat medical conditions or are essential to enable an eligible recipient to attain, maintain or reg…

To transform lives. Working with our partners, we design and deliver innovative, high-quality health and human services that improve the security and promote independence for New Mexicans in their communities.

Medically necessary services are reimbursed by the MAD under Title XIX of the Social Security Act as amended, or by state statute.

New Mexico Health Care Authority.

A. Billing for services: MAD only makes payment to a provider or to the following individuals or organizations for services: (1) a government agency or third party with a court order, based on a valid provider payment assignment; see 42 CFR Section 447.10(d)(e); or (2) a business…

A. Claims must be received within the MAD filing limits as determined by the date of receipt by MAD or its selected claims processing contractor. (1) Claims for services must be received within 90 calendar days of the date of service unless an alternative filing limit is stated w…

To receive payment for services furnished to an eligible recipient or member who is also entitled to medicare, a provider must first bill the appropriate medicare payer. The medicare payer pays the medicare covered portion of the bill. After medicare payment, MAD pays the amount …

MAD only makes payment to a provider who actually rendered the services. However, in the following instances a MAD provider can bill and be paid for covered contracted services. A. A provider is reimbursed at encounter rates or other all-inclusive rates that may have some contrac…

A. Payment not allowed: MAD does not pay factors either directly or by power of attorney 42 CFR Section 447.10(h). A factor is an individual or an organization, such as a collection agency or service bureau. B. No reimbursement for the discharge day: An institutional or other res…

MAD charges interest on overpayments and pays interest on underpayments as a result of year-end cost settlements, unless waived. A. Interest periods: Interest accrues from the date of the final determination of costs or from a date required by a subsequent administrative reversal…

The rule applies to the general public.

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 (HHS) under Title XIX of the Social Security Act as amended or by state statute. See Section 27-1-12 et seq.,…

Permanent.

October 1, 2017, unless a later date is cited at the end of a section.

The objective of this rule is to provide instruction for the service portion of the New Mexico medical assistance programs (MAP).

A. "Authorized representative" means the individual designated to represent and act on behalf of the eligible recipient or member's behalf. The member or authorized representative must provide formal documentation authorizing the named individual or individuals to access the iden…

Health care for New Mexico medical assistance program MAP eligible recipients and members is furnished by a variety of providers and provider groups. The reimbursement and billing for these services is administered by MAD. Upon approval of a New Mexico MAD provider participation …

New Mexico Health Care Authority.

For claims for recipients with medical coverage furnished by a third party, such as an insurer or other third party who may be liable for the medical bill, medicaid limits payment for the claim to the medicaid allowed amount less the third party payment amount, not to exceed the …

When MAD makes payments on behalf of eligible recipients, HSD is subrogated to the eligible recipient's right against a third party for recovery of medical expenses to the extent of the payment. See Subsection B of Section 27-2-23 NMSA 1978 (Repl. Pamp. 1991). If the eligible rec…

A. Pay and chase process: When medicaid or a managed care organization (MCO) pays a claim before learning of the existence of health insurance coverage, or before liability has been established, MAD or its contractors seek reimbursement, up to the amount paid. See 42 CFR Section …

Providers must not refuse to furnish services to eligible recipients solely because an insurance company or third party may be liable for payment. See 42 CFR Section 447.20(b). When providers are aware of the existence of health insurance or health plan coverage for eligible reci…

A. Hospital liens: Hospitals are prohibited from imposing liens on potential lawsuit recoveries for the difference between the MAD payment and hospital billed amounts. MAD payment amounts are payment in full. (1) Hospitals furnishing services to eligible recipients who have been …

Providers must notify MAD or its appropriate contractor any time they are contacted by an attorney or another interested party who requests information relating to services furnished to eligible recipients, including information on amounts billed or paid, procedures performed or …

Providers must not advise or recommend that eligible recipients cancel their health coverage. Failure to comply with this provision is grounds for termination of the provider agreement.

A. MAD has the following responsibilities in administering the TPL program: (1) determining the legal liability of third parties, including health insurers, in paying for the medical services furnished to eligible recipients 42 CFR 433.138(a); (2) pursuing claims and recovery aga…

Individual, blanket, group accident or health policies or certificates of insurance, including employee retirement income security Act (ERISA) plans, delivered, issued or renewed in the state of New Mexico must not contain exclusions or clauses which deny or limit insurance benef…

The rule applies to the general public.

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 and by state statute. See Section 27-2-12 et seq., NMS…

Permanent.

May 1, 2018 unless a later date is cited at the end of a section.

The objective of this rule is to provide instructions for the service portion of the New Mexico medicaid programs.