New Mexico Administrative Code

A. Health care to New Mexico MAP eligible recipients 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 agreement by MAD or its designee, lic…

A. A provider who furnishes services to an MAP eligible recipient must comply with all federal, state, local laws, rules, regulations, executive orders and the provisions of the provider participation agreement. A provider must adhere to MAD program rules as specified in the New …

MAD covers medically necessary prescription drugs and some over-the-counter drugs, subject to the limitations and restrictions delineated in this section of this rule. Claims for injectable drugs, intravenous (IV) admixtures, IV nutritional products and other expensive medication…

A. Legal requirements: All drug items must be assigned a national drug code by the respective manufacturer, repackager or labeler. A prescription must meet all federal and state laws, regulations and rules. A pharmacy provider and a prescriber must fulfill all the requirements of…

Pharmacy services are subject to the limitations and coverage restrictions that exist for other MAD services. A. MAD does not cover the following specific pharmacy items:(1) medication supplied by state mental hospitals to a MAP eligible recipient on convalescent leave from the c…

All MAD services are subject to utilization review for medical necessity and program compliance. Reviews can be performed before services are furnished, after services are furnished and, before payment is made or after payment is made; see 8.302.5 NMAC. Once enrolled, providers r…

Pharmacy providers must submit claims for reimbursement on the separate pharmacy claim form or its successor, see 8.302.2 NMAC and Section 17 of this rule. A. General reimbursement methodology: The estimated ingredient cost will not exceed the lowest of the estimated acquisition …

The point-of-sale system provides relevant drug utilization information that the pharmacist must consider before dispensing a drug. If utilization information indicates that a MAP eligible recipient has an adequate supply of the drug item or that the quantity being dispensed is e…

A. Dispensing frequencies: MAD limits the frequency for which it reimburses the same pharmacy for dispensing the same drug to the same MAP eligible recipient. (1) The limitation is established individually for each drug. (2) Maintenance drugs are subject to a maximum of three tim…

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 or by state statute. See NMSA 1978, Section 27-2-12 et …

Permanent.

January 1, 2014, 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.

[RESERVED]

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.

The New Mexico medical assistance division (MAD) pays for medically necessary health services furnished to MAP eligible recipients, including covered pharmacy services and practitioner administered drugs [42 CFR Section 440.120(a)]. Pharmacy claims must be submitted to the approp…

New Mexico Health Care Authority.

Health care to a MAP eligible recipient 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 agreement (PPA), a licensed practitioner of a faci…

A. A provider who furnishes services to a MAP eligible recipient must comply with all federal, state, local laws, rules, regulations, executive orders and the provisions of his or her PPA. A provider must adhere to the NMAC program rules and program policies that include but are …

A. Vision appliances: MAD covers specific vision care services that are medically necessary for the diagnosis of and treatment of eye diseases. MAD pays a provider for the correction of refractive errors that are required by the condition of the MAP eligible recipient. All servic…

All MAD services are subject to UR for medical necessity and program compliance. Reviews can be performed before services are furnished, after services are furnished, and before payment is made or after payment is made; see 8.302.5 NMAC. MAD makes available on its website and oth…

A. Special requirements for the purchase of wheelchairs: Before billing for a customized wheelchair, the provider who delivers the wheelchair and seating system to a MAP eligible recipient must make a final evaluation to ensure that the wheelchair and seating system meets the med…

The following services are subject to the limitations and coverage restrictions that exist for other MAD services; see 8.302.1 NMAC and 8.310.2 NMAC. The provider must notify the MAP eligible recipient of the coverage limitations prior to providing services. A. Vision appliances:…

Once enrolled, a provider receives instructions on how to access documentation, billing, and claims processing. Reimbursement to a provider for covered services is made at the lesser of the following: (1) the provider's billed charge; or (2) the MAD fee schedule for the specific …

A. Reimbursement for purchase or rental: Unless otherwise specified in this section, the provider's billed charges must be the usual and customary charge for the item or service. The term "usual and customary charge" refers to the amount that the individual provider charges the g…

A. A prosthetic and orthotic service provider must submit claims for reimbursement on the CMS-1500 claim form or its successor. Reimbursement for repairs made by the=]\ provider is made at the actual repair cost plus 50 percent. Repairs made by the manufacturer are reimbursed to …

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 or by state statute. See NMSA 1978, Section 27-1-12 et …

Permanent.

January 1, 2014, 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 medical assistance programs (MAP).

[RESERVED]

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.

The New Mexico medical assistance division (MAD) pays for medically necessary health services furnished to a medical assistance program (MAP) eligible recipient, including covered vision appliances, hearing aids and related services [42 CFR Section 440.60(a) and Section 440.110(c…

New Mexico Health Care Authority.

Health care to a MAP eligible recipient is furnished by a variety of providers and provider groups. Reimbursement and billing for these services are administered by MAD. Upon approval of a New Mexico MAD provider participation agreement (PPA) by MAD or its designee, licensed prac…

A. A provider who furnishes services to a MAP eligible recipient must comply with all federal, state, local laws, rules, regulations, executive orders and the provisions of the provider participation agreement (PPA). A provider must adhere to MAD program rules as specified in the…

MAD reimburses a transportation provider for transportation only when the transport is of a MAP eligible recipient and is subject to the following conditions. A. Free alternatives: Alternative transportation services that can be provided free of charge include volunteers, relativ…

Transportation services are subject to the same limitations and coverage restrictions that exist for other MAD services. See 8.301.3 NMAC. Payments for transportation for any non-covered service is subject to retroactive recoupment. A. MAD does not pay to transport a MAP eligible…

Out-of-state transportation and related expenses require prior authorization by MAD or its designee. Out-of-state transportation is authorized only if the out-of-state medical or behavioral health service is approved by MAD or its designated contractor. Documentation must be avai…

All MAD services are subject to utilization review (UR) for medical necessity and program compliance. Reviews can be performed before services are furnished, after services are furnished, and before payment is made or after payment is made. See 8.302.5 NMAC. The provider must con…

A. Transportation providers must submit claims for reimbursement on the CMS-1500 form or its successor. See 8.302.2 NMAC. Reimbursement to transportation, meal or lodging providers for covered services is made at the lesser of the following: (1) the provider's billed charge: (a) …

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 or by state statute. See NMSA 1978, Section 27-1-12 et …

Permanent.

January 1, 2014, 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).

[RESERVED]

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.