New Mexico Administrative Code

New Mexico Health Care Authority.

A provider who is dissatisfied with a medical necessity or LOC decision by MAD, its UR contractor or a MAD designee, can request reconsideration. An eligible recipient who is dissatisfied with a medical necessity or LOC decision by MAD, its UR contractor or a MAD designee, can re…

MAD has established a process to determine if an individual is eligible to request a HSD administrative hearing. MAD has also established a process for an individual or the individual's authorized representative to request an HSD administrative hearing when an UR reconsideration …

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 Section 27-1-12 et seq. NMSA 1…

Permanent.

August 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 medicaid 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.

A. Utilization review (UR) decisions are those decisions the medical assistance division (MAD), its utilization review (UR) contractor or a MAD designee makes regarding the medical necessity of services or items that require authorization for medical necessity or a level of care …

New Mexico Health Care Authority.

MAD permits facilities to request retroactive prior approval review of long-term care abstracts which are not submitted for level-of-care reviews within the applicable time period if certain conditions are met. A. Initial abstracts: Facilities must submit a request for retroactiv…

A. To request retroactive prior approval review, a facility must submit the abstract, a request for retroactive prior approval review form and supporting documentation to the UR contractor. Facilities must provide at least the following supporting documentation: (1) pertinent inf…

Providers who disagree with abstract review decisions or denials of retroactive prior approval review can request a re-review and reconsideration. See Section MAD-953, Reconsideration of Utilization Review Decisions for specific information on the review process.

Medicaid reimburses facilities in the following manner after approval of a retroactive prior approval review: A. for late initial abstracts caused by delayed physician signature, reimbursement is effective back to the date of admission; B. for late initial abstracts caused by del…

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

November 1, 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 medical assistance division (MAD) utilization review (UR) contractor performs prior approval and abstract review on admissions, readmissions, and continued stay requests for all long-term care nursing facilities (NF) and intermediate care facilities for the mentally retarded …

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 and by the state health care authority pursuant to state statute. See NMSA 1978 Sectio…

Permanent.

November 1, 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.

A. General Reconsideration Process: Medicaid providers who disagree with an audit settlement can submit a written request for a reconsideration to the New Mexico Medical Assistance Division (MAD) within thirty (30) calendar days of the date on the notice of final settlement. The …

New Mexico Health Care Authority.

MAD is required to impose sanctions against a provider for violation of the provisions outlined in the MAD NMAC rules and federal and state laws and regulations. MAD has discretion to impose monetary or non-monetary sanctions against providers for fraud or other forms of miscondu…

HSD is allowed to impose monetary or non-monetary sanctions against any provider or other entity for misconduct. HSD is required to impose certain sanctions against a provider or other entity for fraud, HIPAA violations, and other actions. Sanctions may be applied to any provider…

A. Mandatory sanctions: MAD must impose sanctions when a provider receives a formal reprimand or censure for unethical practice by a professional association of the provider's peers or when a provider is suspended or terminated from participation in medicare or any federal or sta…

MAD can seek recovery of overpayments through the recoupment or repayment process. Overpayments are amounts paid to a MAD provider or other entity in excess of the MAD allowable amount. Overpayment amounts must be collected within 24 months of the initiation of recovery. Overpaym…

A. Content of provider notice: With the exception of a referral based on a credible allegation of fraud, as that term is defined in federal statute or regulation or both, when MAD seeks overpayment recovery, or to impose sanctions or remedies, written notice is sent to the provid…

A provider can request a hearing if he or she disagrees with any of the aforementioned actions taken or sanctions or remedies imposed by MAD, as applicable. Requests for a HSD provider administrative hearing must be made within 30 calendar days or within the time limit specified …

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 medical assistance division (MAD) is required to impose sanctions or penalties against providers for fraud, violations of federal or state law, violations of HIPAA regulations, failure to meet professional standards of conduct, non-compliance with the medical assistance divis…

New Mexico Health Care Authority.

The following constitute an adverse action for which an individual may request a MCO appeal and a HSD administrative hearing. A. The denial or reduction by MAD, its UR contractor, or a MCO of an authorized service or item, including level of care (with the exception of a MCO valu…