All MAD services are subject to utilization review for
medical necessity and program compliance. Reviews may 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 Authorization
and Utilization Review. It is the provider's responsibility to access
these instructions or ask for paper copies to be provided, to understand the
information provided, to comply with the requirements, and to obtain answers to
questions not covered by these materials. When services are billed to and paid
by a coordinated services contractor authorized by HCA, the provider must
follow that contractor's instructions for authorization of services.
A. Prior authorization: Certain procedures or
services may require prior authorization from MAD or its designee. A procedure
that requires prior authorization is primarily one for which the medical
necessity may be uncertain, which may be for cosmetic purposes, or which may be
of questionable effectiveness or long-term benefit.
(1) All transfers from one acute care DRG
reimbursed hospital to another DRG reimbursed hospital.
(2) All inpatient stays for a PPS-exempt
psychiatric unit of a general acute care hospital requires admission and
continued stay reviews.
(3) All
inpatient stays in a rehabilitation hospital, a PPS-exempt rehabilitation unit
in a general acute care hospital, and an extended care or other specialty
hospital requires admission and continued stay reviews.
(4) Outpatient physical, occupational, and
speech therapies services require prior authorization.
(5) Services for which prior authorization
was obtained remain subject to utilization review at any point in the payment
process.
B. Eligibility
determination: Prior authorization of services does not guarantee that an
individual is eligible for MAD services. A provider must verify that an
individual is eligible for the MAD services at the time services are furnished
and determine if an eligible recipient has other health insurance.
C. Consideration: A provider who disagrees
with a prior authorization request denial or another review decision may
request a re-review and a reconsideration. See MAD-953, Reconsideration
of Utilization Review Decisions.
