N.M. Admin. Code § 8.310.4.13 - UTILIZATION REVIEW

All medicaid services are subject to utilization review for medical necessity and program compliance. Reviews can be performed before services are furnished, after services are furnished and before payment is made, or after payment is made. See 8.302.5 NMAC, Prior Approval and Utilization Review. Once enrolled, providers receive instruction and documentation forms necessary for prior approval and claims processing.

A. Prior approval: Certain procedures and services can require prior approval from MAD or its designee. Services for which prior approval was obtained remain subject to utilization review at any point in the payment process.

B. Eligibility determination: Prior approval of services does not guarantee that the individuals are eligible for medicaid. Providers must verify that individuals are eligible for medicaid at the time services are furnished and determine if medicaid clients have other health insurance.

C. Reconsideration: Providers who disagree with prior approval request denials or other review decisions can request a rereview and a reconsideration. See 8.350.2 NMAC, Reconsideration of Utilization Review Decisions.

Notes

N.M. Admin. Code § 8.310.4.13

2/1/95; 1/1/00; 8.310.4.13 NMAC - Rn, 8 NMAC 4.MAD.713.4, 11/1/04, Adopted by New Mexico Register, Volume XXXV, Issue 12, June 25, 2024, eff. 7/1/2024