New Mexico Service Delivery Resources and Policies
Rendering services and seeking reimbursement within Medicaid or other state funds has several requirements. Be sure to become familiar with each of them, including the policies of the Managed Care Organizations (MCOs) that your agency contracts with. Each MCO has their own provider manual that you will want to become familiar with. Some NMACs below may not apply to all providers or all services. If you have questions, be sure to contact our clinical team, your MCO, or the Medical Assistance Division (MAD).
Billing for Medicaid Services
– 8.302.1 NMAC — Social Services, General Provider Policies
- Eligible providers
- Provider responsibilities and requirements
- Eligible Medicaid recipients
- Record-keeping and documentation requirements
- Patient confidentiality
- Provider disclosure
- Termination of provider status
– 8.302.2 NMAC — Social Services, Billing for Medicaid Services
- Claims limitations
- Dual-eligible recipients (Medicare/Medicaid)
- CPT/HCPCS service unit time frames
- Timely filing
– 8.310.2 NMAC — Social Services, Health Care Professional Services, General Benefit Description
– 8.321.2 NMAC — Social Services, Specialized Behavioral Health Services, Specialized Behavioral Health Provider Enrollment and Reimbursement
There are special regulations governing those who are Medicare eligible and/or dual eligible. While some provider licensure types may not be eligible to provide services under Medicare, it is important not to turn away clients before fully understanding the process for coverage and eligibility within both Medicare and Medicaid. Be sure to contact your contracted MCO and review all applicable regulations at the main HDS website in the “Provider” section, including the following rules for direction:
- Medicaid’s relationship to Medicare — 8.310.2.10 NMAC
- Dual eligibility — 8.302.2.12 NMAC
Additional rules that apply to some services and providers
- 7.20.2 NMAC —Health, Mental Health, Comprehensive Behavioral Health Standards
- 7.21.1 NMAC — Health, Behavioral Health, General Provisions
- 7.32.2 NMAC — Health, Alcohol and Drug Abuse, Admission Criteria for Alcohol Substance Service
Level of Care Guidelines (LOCG) and Prior Authorization
Be sure to contact your MCO as to the appropriate forms and processes for both LOCG and Prior Authorization services, including treatment plans and specialty services.
Critical Incident Reporting
It is important to work with your contracted MCOs, Optum Health NM, and/or Xerox as appropriate on reporting critical incidents. Each New Mexico State Department may have its own reporting protocols. Anyone billing Medicaid, state, or other federal funds received through the state must report critical incidents. There is a HSD/BHSD state-issued BH CIR Protocol issued as of 2015 that all payors have been provided. That protocol is downloadable from the HSD Portal which is an online entry system that requires login. Please use the email address at the portal to request further information about using the portal. The CIR portal can be found here.
You may request Technical Assistance (TA) from either the MCOs or the State Department from which you are seeking reimbursement to help inform your practice and to understand how the rules above apply and/or should be operationalized. Email firstname.lastname@example.org for information on TA for behavioral health-related service and program delivery or provider allowances.