N.M. Admin. Code § 8.285.600.11 - INITIAL BENEFITS
Applications for medicaid must be acted on within 45 days of the date of application.
A. If an
applicant is eligible for medicaid, the individual is sent a notice of case
action (NOCA) form. The approval of financial eligibility is not a guarantee
that medicaid will pay for the services. The NOCA form also serves as notice of
case closure, since medicaid covers only emergency services received during the
specified term of the emergency. The provider is sent the decision for
emergency medical services for non-citizens (EMSNC) application (MAD 778) form.
The provider must use the MAD 778 form to submit claims to the medicaid
utilization review contractor for emergency review.
B. If an applicant is ineligible for medicaid
or a decision on the application is delayed beyond the 45 day time limit, the
individual is sent a NOCA form regarding the application for EMSNC. The NOCA
form explains the reason for denial or delay and informs the applicant of their
right to an administrative hearing. If the application is denied, the applicant
must notify providers of the denial.
C. The applicant is responsible for payment
for the medical services if they fail to apply promptly for coverage, verify
eligibility for coverage, or notify the provider of the approval or denial of
the application.
Notes
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