N.M. Admin. Code § 8.326.2.17 - REIMBURSEMENT
A. Case management
providers must submit claims for reimbursement on the HCFA-1500 claim form or
its successor. See 8.302.2 NMAC, Billing for Medicaid Services. Instructions on
documentation, billing and claims processing are sent to approved medicaid
providers. Reimbursement for covered case management services is made at the
lesser of the following:
(1) the provider's
billed charge; or
(2) the MAD fee
schedule for the specific service or procedure.
B. The provider's billed charge must be their
usual and customary charge for an average month of services to individuals who
are part of the target population. Monthly charges are based on a cost analysis
conducted periodically by the HCA.
C. "Usual and customary charge" refers to the
amount which the individual providers charge the general public in the majority
of cases for a specific procedure or service.
D. For case management services furnished by
an institution, costs associated with case management must be removed from
their cost reports prior to cost settlement or rebasing.
Notes
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