N.M. Admin. Code § 8.310.2.9 - [Effective until 7/1/2025] GENERAL PROGRAM DESCRIPTION
A. The New Mexico medical assistance division
(MAD) pays for medically necessary health care services furnished by a MAD
enrolled medical provider. See
42 CFR
440.210; Section 27-2-16 NMSA 1978 (Repl.
Pamp. 1991).
B. MAD pays for
medically necessary behavioral health professional services including
assessments, evaluations, and therapy required by the condition of the medical
assistance program (MAP) eligible recipient. See
42
CFR Sections 440.40,
440.60(a)
and 441.571.
C. MAD covers services
which are medically necessary for the diagnosis or treatment of illnesses,
injuries or conditions of a MAP eligible recipient, as determined by MAD or its
designee. All services must be furnished within the limits of the MAD New
Mexico administrative code (NMAC) rules policies and instructions within the
scope of practice defined by the provider's licensing board, scope of practice
act, or regulatory authority. Any claim submitted for reimbursement is subject
to review by MAD or its designee to verify the medical necessity of the
service. All claims are subject to pre-payment or post-payment review and
recoupment.
D. HSD, through MAD, is
responsible for the administration of the medicaid program and other health
care programs. This joint federal and state program provides payment for
medically necessary health services furnished to MAP eligible
recipients.
E. A provider must be
eligible for participation as a MAD approved provider at the time services are
furnished. MAD does not cover services performed during a time period when the
provider or facility did not meet required licensing or certification
requirement.
F. If a MAP eligible
recipient is enrolled with a MAD managed care organization (MCO), the provider
must contact that member's MCO for specific reimbursement information. A MCO
contracted with the state of New Mexico is not required to follow the MAD
fee-for-service (FFS) fee schedules or reimbursement methodologies unless
otherwise instructed by MAD. Reimbursement arrangements are determined
contractually between the MCO and the provider.
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
A. The New Mexico medical assistance division (MAD) pays for medically necessary health care services furnished by a MAD enrolled medical provider. See 42 CFR 440.210; Section 27-2-16 NMSA 1978 (Repl. Pamp. 1991).
B. MAD pays for medically necessary behavioral health professional services including assessments, evaluations, and therapy required by the condition of the medical assistance program (MAP) eligible recipient. See 42 CFR Sections 440.40, 440.60(a) and 441.571.
C. MAD covers services which are medically necessary for the diagnosis or treatment of illnesses, injuries or conditions of a MAP eligible recipient, as determined by MAD or its designee. All services must be furnished within the limits of the MAD New Mexico administrative code (NMAC) rules policies and instructions within the scope of practice defined by the provider's licensing board, scope of practice act, or regulatory authority. Any claim submitted for reimbursement is subject to review by MAD or its designee to verify the medical necessity of the service. All claims are subject to pre-payment or post-payment review and recoupment.
D. HSD, through MAD, is responsible for the administration of the medicaid program and other health care programs. This joint federal and state program provides payment for medically necessary health services furnished to MAP eligible recipients.
E. A provider must be eligible for participation as a MAD approved provider at the time services are furnished. MAD does not cover services performed during a time period when the provider or facility did not meet required licensing or certification requirement.
F. If a MAP eligible recipient is enrolled with a MAD managed care organization (MCO), the provider must contact that member's MCO for specific reimbursement information. A MCO contracted with the state of New Mexico is not required to follow the MAD fee-for-service (FFS) fee schedules or reimbursement methodologies unless otherwise instructed by MAD. Reimbursement arrangements are determined contractually between the MCO and the provider.