A provider who furnishes services to a medicaid eligible
recipient agrees to comply with all federal and state laws, regulations, and
executive orders relevant to the provision of services. A provider also must
conform to MAD program rules, instructions, and program directions and billing
instructions, as updated. A provider is also responsible for following coding
manual guidelines and CMS correct coding initiatives, including not improperly
unbundling or upcoding services. A provider must verify that individuals are
eligible for a specific health care program administered by the HCA and its
authorized agents and must verify the eligible recipient's enrollment status at
the time services are furnished. A provider must determine if an eligible
recipient has other health insurance. A provider must maintain records that are
sufficient to fully disclose the extent and nature of the services provided to
an eligible recipient.
A. Eligibility
determination: A provider must verify recipient eligibility prior to providing
services and verify that the recipient remains eligible throughout periods of
continued or extended services.
(1) A provider
may verify eligibility through several mechanisms, including using the
automated voice response system, contacting MAD or designated contractor
eligibility help desks, contracting with an eligibility verification system
vendor, or by using the New Mexico medicaid portal.
(2) An eligible recipient becomes financially
responsible for a provider claim if the eligible recipient:
(a) fails to identify themselves as a MAD
eligible recipient; or
(b) fails to
state that an eligibility determination is pending; or
(c) fails to furnish MAD identification
before the service is rendered and MAD denies payment because of the resulting
inability of the provider to be able to file a claim timely; or
(d) receives services from a provider that
lacks MAD enrollment, is not eligible to provide the services or does not
participate in MAD programs.
B. Requirements for updating information: A
provider must furnish MAD or the appropriate MAD claims processing contractor
with complete information on changes in their address, license, certification,
board specialties, corporate name or corporate ownership, and a statement as to
the continuing liability of the provider for any recoverable obligation to MAD
which occurred or may have occurred prior to any sale, merger, consolidation,
dissolution or other disposition of the provider or person. MAD or the
appropriate MAD claims processing contractor must receive this information at
least 60 calendar days before the change. Any payment made by MAD based upon
erroneous or outdated information is subject to recoupment or provider
repayment. The provider must provide MAD with information, in writing, updating
their provider participation agreement of any conviction of delineated criminal
or civil offenses against the provider or parties with direct or indirect
ownership or controlling interest within 10 calendar days after the
conviction.
C. Additional
requirements: A provider must meet all other requirements stated in the program
rules, billing instructions, manual revisions, supplements, and signed
application forms or reverification forms, as updated. MAD may require a letter
of credit, a surety bond, or a combination thereof, from the provider. The
letter of credit, surety bond or combination thereof may be required if any one
of the following conditions is met:
(1) the
provider is the subject of a state or federal sanction or of a criminal, civil,
or departmental proceeding in any state;
(2) a letter of credit, surety bond, or any
combination thereof is required for each provider of a designated provider
type;
(3) the provider cannot
reasonably demonstrate that they have assumed liability and are responsible for
paying the amount of any outstanding recoveries to MAD as the result of any
sale, merger, consolidation, dissolution, or other disposition of the provider
or person; or
(4) the secretary
determines that it is in the best interest of MAD to do so, specifying the
reasons.
