New Mexico Administrative Code

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 furnishing case management services to an eligible recipient. (1) Government a…

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 for eligible medicaid recipients who meet all of the following criteria: A. individuals who are eighteen (18) years of age or older; B. individuals who are residents of the state of New Mexico; C. individuals who are not residents of an inst…

Medicaid covers the following case management services for adults who have been abused, neglected or exploited: A. services which help recipients gain access to medical, social, educational or other needed services. B. assessment of a recipient's medical and social needs and func…

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 services as adult protective services case management: A. servi…

A. Case managers develop and implement plans of care for each medicaid recipient. Plans of care are developed in consultation and cooperation with recipients, families or legal guardian(s), primary physicians, as appropriate and others involved with the recipient's care. B. The f…

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. Once enrolled, instructions on documentation, billing and claims processing are sent to the medicaid providers. Reimbur…

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 Section 27-2-12 …

Permanent

January 31, 1996

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]

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 case management services furnished to medicaid eligible adults, individuals who are 18 years or older, who have been neglected, abused, or…

New Mexico Health Care Authority.

Upon approval of a New Mexico medical assistance program provider participation agreement by the New Mexico medical assistance division (MAD), the following agency is reimbursed for furnishing case management services to clients in the identified population: New Mexico children, …

Providers who furnish services to medicaid clients 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 if…

Medicaid covers case management services furnished to medicaid clients under nineteen (19) years of age who are involved with the juvenile justice system or who have committed a delinquent act and have an identified physical or mental condition which has a high probability of imp…

Case management is defined as services which assist clients in the target population in gaining access to needed medical, social, educational and other services. A. Medicaid covers the following case management service activities for clients in the target population: (1) assessme…

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. In addition, medicaid does not cover the following specific activities: A. services furnished to individuals w…

A. Case managers develop and implement plans of care in conjunction with the clients, families or legal guardian(s), therapists, physicians or others who assist with the client's care. B. The following must be contained in the plan of care or documents used in the development of …

All medicaid services are subject to utilization review for medical necessity and program compliance. Case management services furnished to clients in this targeted population do not require prior approval. Reviews can be performed before services are furnished, after services ar…

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. A. 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 Section 27-2-12 …

Permanent

March 1, 2000

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]

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 human services department (HSD) pays for medically necessary case management services furnished to identified clients under nineteen (19) years of age who are under the supervision of a juvenile probation and parole officer (JPPO) and have an identified physical or…

New Mexico Health Care Authority.

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…

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 …

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) …

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 recipien…

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 decis…

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)…

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 …

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 Section 27-2-12…

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.

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 …