N.M. Code R. § 8.310.12.12 - COVERED SERVICES
MAD covers medically necessary services and procedures for
the diagnosis and treatment of an illness or injury as indicated by the
eligible recipient's condition. Services must be furnished within the limits of
MAD rules and within the scope of practice of the provider's professional
standards. Public health services including services by public health nurses
are covered to the same extent their services would be covered for non-IHS
public health facilities. Limitations on covered services based on age and
category of eligibility also apply to services rendered at an IHS or tribal 638
A.
Outpatient encounters and
visits: An outpatient encounter or visit is face-to-face contact between
a practitioner and an eligible recipient as documented in the eligible
recipient's physical or behavioral health record. An encounter or visit can
occur at an IHS facility , tribal 638 facility , or a MAD recognized offsite
location including IHS or tribal facility -based services that are provided in
the home or in community centers or other locations but the medical records and
the supervision or direction of the service comes from the eligible facility .
To be billable as an encounter, the eligible recipient must be seen by a level
of practitioner who would be eligible to be enrolled as a MAD provider or a
practitioner comparable to that required by other service and provider rules or
the service must be supervised by a level of practitioner who would be eligible
to be enrolled as a MAD provider or a practitioner comparable to that required
by other service and provider rules. Examples include but are not limited to
the following: audiologist, behavioral health professional, certified nurse
midwife, certified nurse practitioner, clinical nurse specialist, clinical
pharmacy specialist, dentist, dental hygienist, licensed dietician,
occupational therapist, optometrist, pharmacist clinician, physician assistant,
physician, physical therapist, podiatrist, speech therapist and other provider
types within their scope of practice as designated by MAD; see 8.310.2 NMAC,
8.310.3 NMAC and 8.321.2 NMAC.
(1) Visits to
the same facility , on the same day, for the same or related diagnosis
constitutes a single encounter.
(2)
Multiple encounters can occur on the same date of service when the services are
distinct. The following are examples of types of separate encounters:
(a) an eligible recipient receives a service
that is not associated with the initial encounter and the service provided is
for a different principal diagnosis; or
(b) an eligible recipient is seen at two
different facilities (different provider numbers) and one of the facilities is
unable to provide the necessary services for the diagnosis or treatment of the
eligible recipient's condition.
(3) An outpatient encounter may be billed
when a visit consists of services that could be provided in a physician's
office such as instructions to a diabetic, medication management, and
anticoagulant management, when provided by a qualified individual as part of a
facility -based outpatient program if no other related encounter occurs that
day, similar to how services would be covered for other providers and clinics
in other MAD service rules.
(4) An
outpatient encounter may be billed when an eligible recipient returns at a
later date for a follow up MAD service such as a laboratory, radiology, or
therapy service which does not require an additional physician visit if no
other related visit occurs that day.
(5) When a MAD service typically requires
multiple visits such as orthodontia services, crowns, and dentures, the
provider may bill an amount for the initial service that includes the standard
number of encounters for the service are for the standard number of visits,
similar to how services would be covered for other providers in other MAD
service rules, or be paid at a fee schedule amounts that closely approximates
the appropriate payment for multiple services.
B.
Inpatient hospital stays: An
inpatient hospital stay occurs when an eligible recipient is admitted and stays
overnight.
C.
Services not
subject to office of management and budget (OMB) codes or rates: Some
services are covered by MAD when occurring within an IHS or a tribal facility
but are not included or billed at the OMB rate. These services are covered to
the extent described under applicable rules for the service, and include:
(1) anesthesia (professional
charges);
(2) ambulatory surgical
center facility services;
(3)
targeted case management;
(4)
hearing appliances (hearing testing is reimbursed at the OMB rate);
(5) physician inpatient hospital visits and
surgeries;
(6) smoking
cessation;
(7) vision appliances,
including frames, lenses, dispensing, and contacts (vision exams are at the OMB
rate); and
(8) telemedicine's
originating site facility fee; a telemedicine originating site fee is covered
when the requirements of 8.310.2 NMAC are met; both the originating and distant
sites may be IHS or tribal facilities at two different locations or if the
distant site is under contract to the IHS or tribal facility and would qualify
to be an enrolled provider; a telemedicine originating site fee is not payable
if the telemedicine technology is used to connect an employee or staff member
of a facility to the eligible recipient being seen at the same facility ;
however, even if the service does not qualify for a telemedicine originating
site fee, the use of telemedicine technology may be appropriate thereby
allowing the service provided to meet the standards to qualify as an encounter
by providing the equivalent of face-to-face contact.
D.
Behavioral health services:
(1) Outpatient behavioral health services
billed using the outpatient OMB codes include assessments and evaluations,
outpatient therapies, comprehensive community support services (CCSS), and
other services as approved by MAD.
(2) Other specialized behavior health
services may be reimbursed at the MAD fee for service (FFS) rate or at an OMB
rate, as agreed between the facility and MAD.
(3) Prior to billing specialized behavioral
health services including CCSS, the IHS or tribal 638 facility must submit
documentation to MAD demonstrating the ability to adhere to the service
definitions and standards for the specific service; see 8.321.2 NMAC.
E.
Pharmacy services:
See 8.324.4 NMAC for an IHS and a tribal 638 facility enrolled as a pharmacy.
Pharmacy services are not part of the OMB rate. Pharmacy claims are not limited
to a 30 or 90 day supply when the prescriber has written for a larger days'
supply of medication. Pharmacy claims may exceed the days' supply limitations
if the amounts dispensed at one time is reasonable. IHS and tribal 638 facility
pharmacy claims are not subject to formularies or preferred drug lists or
authorization as the facility maintains its own formulary.
F.
Transportation services: For
a detailed description of transportation services, see 8.324.7 NMAC.
Notes
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