N.M. Admin. Code § 8.314.5.18 - PRIOR AUTHORIZATION AND UTILIZATION REVIEW

All MAD services, including services covered under the DDW, 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 8.310.2 NMAC. Once enrolled, providers receive instructions and documentation forms necessary for prior authorization and claims processing.

A. MAD prior authorization: To be eligible for DDW services, a MAD eligible recipient must require the level of care (LOC) of services provided in an ICF-IID. LOC determinations are made by MAD or its designee. The eligible recipient's person centered ISP must specify the type, amount and duration of services and meet clinical criteria. Certain procedures and services specified in the ISP may require prior authorization from MAD or its designee. Services for which prior authorization was obtained remain subject to utilization review at any point in the payment process.

B. DOH prior authorization: Certain services are subject to utilization review by DOH.

C. Eligibility determination: Prior authorization of services does not guarantee that individuals are eligible for MAD services. Providers must verify that individuals are eligible for MAD services, including DDW services or other health insurance prior to the time services are furnished. An eligible recipient may not be institutionalized, hospitalized, or receive personal care option (PCO) services or other HCBS waiver services at the time DDW services are provided, except for certain case management services that are required to coordinate discharge plans or transition of services to DDW services.

D. Third party assessor review process: All services for DDW recipients will be reviewed by the TPA contracted by MAD. The TPA will adhere to deadlines set forth in its contract with the MAD. The TPA will make a clinical determination on whether the requested services and service amounts are needed, and will recommend whether the requested annual budget and ISP should be approved. If the TPA approves in whole or part the requested ISP and budget, the TPA will enter the approved portion of the budget into the medicaid management information system and issue a prior authorization to the case manager. If there is a denial in part or whole, the TPA decision must be in writing, identify a list of all documents and input considered by the TPA team during its review, and state the reasons for any denial of requested services. The eligible recipient, case manager, and guardian (if applicable) will be provided with this written determination and notice of an opportunity to request a fair hearing as well as an agency review conference.

(1) The eligible recipient, case manager, and guardian (if applicable) may submit to the TPA additional information relating to support needs.

(2) The decision of the TPA approving services requested by the DDW participant is binding on the State. However, the state may agree to overturn a decision to deny services requested by the DDW participant at a requested agency conference.

E. Reconsideration: Providers who disagree with the denial of a prior authorization request or other review decisions may request a reconsideration. See 8.350.2 NMAC, Reconsideration of Utilization Review Decisions.

Notes

N.M. Admin. Code § 8.314.5.18

8.314.5.18 NMAC - N, 11-1-12; 8.314.5.18 NMAC - Rn & A, 8.314.5.17 NMAC, 6-15-14, Amended by New Mexico Register, Volume XXVI, Issue 02, January 30, 2015, eff. 2/1/2015, Adopted by New Mexico Register, Volume XXVII, Issue 04, February 29, 2016, eff. 3/1/2016, Adopted by New Mexico Register, Volume XXIX, Issue 22, November 27, 2018, eff. 12/1/2018, Amended by New Mexico Register, Volume XXXIII, Issue 06, March 22, 2022, eff. 4/1/2022, Amended by New Mexico Register, Volume XXXV, Issue 05, March 12, 2024, eff. 4/1/2024