New Mexico Administrative Code

Brain injury services fund (BISF) services are provided through two contractor components, service coordination and fiscal intermediary agent for BISF HCBS. A. Service coordination services: Service coordination services serve a problem-solving function. They are intended to reso…

Contracted entities and providers, who provide direct BISF services, must avoid conflict of interest or duplication of services and may not: A. provide direct intervention services, such as individual therapy, group therapy, support groups, homemaker services, personal attendant …

An independent living plan (ILP) is required for each interim service period that includes all the services, goods, and supports recommended to the participant including referrals to BISF HCBS and any other potential resources available in the local community that are needed to r…

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 pa…

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 cel…

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 reimburse…

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 reg…

This rule applies to the general public.

Subsection E of Section 9-23-6 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.

Permanent.

April 1, 2021, unless a later date is cited at the end of a section.

The objective of this rule is to establish policies and procedures and define standards of the New Mexico human services department (HSD) brain injury services fund program. The brain injury services fund program provides timely short term in-state non-medicaid services for perso…

A. "Acquired brain injury" (ABI) means a brain injury that is the result of trauma arising from an insult to the brain from an outside physical force via open or closed head injury; shaken baby syndrome; anoxia; near-drowning; electrical shock; brain infection; brain tumors; cere…

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.

Enrollment into the BISF, as a non-entitlement program, is on a voluntary basis and occurs in up to six month increments. To be eligible for the BISF program, an applicant with a crisis need must meet the following requirements: A. Diagnosis: Individuals are eligible for BISF ser…

New Mexico Health Care Authority.

A. Upon approval of New Mexico medical assistance program provider participation agreements by the New Mexico medical assistance division (MAD), the following agencies are eligible to be reimbursed for providing case management services: (1) state agencies in New Mexico providing…

Providers who furnish services to medicaid recipients must comply with all specified medicaid participation requirements. See 8.302.1 NMAC, General Provider Policies. Providers must verify that individuals are eligible for medicaid at the time services are furnished and determine…

A. Case management services are available for eligible medicaid recipients that meet all of the following criteria:(1) 21 years of age or older; (2) resident of the state of New Mexico; (3) meet the state definition of an individual with a developmental disability; (4) placement …

Medicaid coverage for case management services varies by the priority assigned recipients by the CST. A. Case management services for recipients assigned a priority three: Case management services for recipients assigned a priority three are limited. Medicaid covers assessments o…

Case management services are subject to the limitations and coverage restrictions which exist for other medicaid services. See 8.301.3 NMAC, General Noncovered Services. Medicaid does not cover the following specific activities: A. services furnished to individuals who are not me…

A. Case managers develop and implement plans of care (POC) based on standards developed by the developmental disabilities division of the HCA. For purposes of compliance with medicaid regulations, the following must be contained in the plan of care or documents used to develop th…

All medicaid 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, Prior Approval and Ut…

A. Case management providers must submit claims for reimbursement on the HCFA-1500 claim form or its successor. See 8.302.2 NMAC, Billing for Medicaid Services. Instructions on documentation, billing and claims processing are sent to approved medicaid providers. Reimbursement for…

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, and by the state health care authority pursuant to state statute. See Sections 27-2-1…

Permanent.

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

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.

The New Mexico medical assistance program (medicaid) pays for medically necessary health services furnished to eligible recipients, including covered case management services furnished to adult recipients who have developmental disabilities. This part describes eligible providers…

New Mexico Health Care Authority.

A. Upon approval of New Mexico medical assistance program provider participation agreements by the New Mexico medical assistance division (MAD), the following certified agencies are eligible to be reimbursed for furnishing case management services to eligible pregnant individuals…

Providers who furnish services to medicaid recipients must comply with all specified medicaid participation requirements. See 8.302.1 NMAC, General Provider Policies. Providers must verify that individuals are eligible for medicaid at the time services are furnished and determine…

Case management services are available to medicaid eligible pregnant individuals and their infants up to 12-months following the delivery in accordance with 8.291.400.14 NMAC.

Medicaid covers case management services for pregnant individuals and their infants which help recipients gain access to medical, social, educational or other needed services. Case management services provide necessary coordination with providers of non-medical services, such as …

Case management services are subject to the limitations and coverage restrictions which exist for other medicaid services. See 8.301.3 NMAC, General Noncovered Services. Medicaid does not cover the following specific activities: A. services furnished to individuals who are not me…

A. Case managers develop and implement plans of care for each medicaid recipient. Plans of care are developed in consultation with the recipients, families or legal guardian(s), physicians and others involved with care. B. The following must be contained in the plan of care or do…

All medicaid 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, Prior Authorization a…

A. Case management providers must submit claims for reimbursement on the HCFA 1500 claim form or its successor. See 8.302.2 NMAC, Billing for Medicaid Services. Instructions on documentation, billing and claims processing are sent to approved medicaid providers. Reimbursement for…

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 and by the state health care authority pursuant to state statute. See Sections 27-2-12…

Permanent

February 1, 1995

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.

[RESERVED]

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.

The New Mexico medical assistance program (medicaid) pays for medically necessary health services furnished to eligible recipients, including case management services furnished to medicaid eligible pregnant individuals on the day the pregnancy ends through the last day in which t…

New Mexico Health Care Authority.