N.M. Admin. Code § 8.326.6.17 - 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 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 services.
C. "Usual and customary charge" refers to the
amount which the individual provider charges 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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