Section He-M 520.06 - Payment for Health-Related Services(a) SMS shall approve a recipient's request for payment for a health-related service when all the following are true:(1) The recipient has been determined to be financially eligible in accordance with He-W 520.05;(2) The health-related service is: a. Determined to be medically necessary;b. Related to the recipient's chronic medical condition; andc. Supported by the recipient's SMS health care plan;(3) All third party resources, including the recipient's hospital, surgical, or medical insurance plans, have been exhausted, except as allowed by (f) below; and(4) A bill or invoice for a health-related service is submitted to SMS: a. Which is itemized and dated; andb. For which the service date is: 1.Not more than 12 months prior to the submission date;
2.Not prior to the recipient's application date; and
3.Not a date when the recipient was not eligible for financial assistance.
(b) Payments for health-related services shall be paid at the lowest of: (1) The provider's usual and customary charge to the public, as defined in RSA 126-A:3, III(b) ;(2) The lowest amount accepted from any other third party payors; or(3) The Medicaid rate established by the department in accordance with RSA 161:4, VI(a) .(c) Payment for hospital charges shall: (1) Include both inpatient and outpatient services; and(2) Have a maximum of $3,000 per event.(d) Payment for diagnostic procedures shall have a maximum of $3,000 per procedure.(e) Notwithstanding (b) above:(1) Over-the-counter medication and non-prescription medication items shall be paid as submitted if no current Medicaid rate is available; and(2) The administrator shall approve reimbursement for health-related services over Medicaid rates when:a. SMS has negotiated a higher payment rate(s) with the provider; orb. Medicaid reimbursement is less than what was paid out of pocket by the recipient.(f) The administrator shall approve reimbursement for health-related services not submitted for Medicaid or third-party reimbursement when: (1) A Medicaid or TPL precedent has been set for denial of equivalent services;(2) A crisis situation exists that jeopardizes the safety or health of the recipient;(3) The service is identified in the recipient's SMS health care plan; or(4) The volume of service is over Medicaid or TPL allowable limits.(g) With respect to Title XIX, Medicare, or any medical insurance program or policy, SMS shall be the payor of last resort. Nothing contained in these rules shall require SMS to provide payment for medications, supplies, or services.N.H. Admin. Code § He-M 520.06
Amended by Volume XXXVIII Number 28, Filed July 12, 2018, Proposed by #12557, Effective 6/26/2018, Expires 12/24/2018.The amended version of this section by New Hampshire Register Volume 39, Number 02, eff.12/28/2018 is not yet available.