Section He-W 521.05 - Provider Payments(a) Payment for a medical item, supply, or service shall be made for a recipient if:(1) The recipient is eligible for medicaid on the date(s) of service(s);(2) The medical item, supply, or service is covered under the medicaid program, in accordance with He-W 500;(3) The provider is an enrolled medicaid provider at the time the service is provided; and(4) A claim has been properly completed and submitted to the department's fiscal agent or MCO for payment.(b) A claim shall be denied when all of the requirements described in (a) above are not met.(c) Reimbursement for any item, supply, or service rendered shall be the lesser of the following: (1) Fee-for-service claims rate as established by the department in accordance with RSA 161:4, VI(a);(2) The provider's usual and customary charge; or(3) The third party's patient liability up to the medicaid allowable amount.(d) Reimbursement for any item, supply, or service that is first paid by Medicare shall be as follows: (1) The full co-pay or deductible for hospital inpatient and outpatient claims; or(2) The co-pay, deductible, or co-insurance up to the medicaid allowable amount less the Medicare payment for all other medical services and supplies. If the Medicare payment is greater than the medicaid allowable, then medicaid shall pay zero.(e) Except for inpatient hospitalization and nursing facilities, payment for out-of-state hospitals, as defined by He-W 543.01(n), not in the medicaid network, shall be made: (1) At the allowable medicaid rate in the state in which the services are provided; or(2) In the absence of a medicaid program, at the approved Medicare rate.(f) Payment for inpatient hospital services shall be made in accordance with He-W 543.13.(h) The provider shall not deny services to any eligible individual due to the individual's inability to pay the cost sharing amount imposed by medicaid in accordance with 42 CFR 447.15, and 42 CFR 447.52-54.(i) The following items or services shall not be reimbursable by medicaid: (1) All services or supplies that are not determined to be medically necessary, as defined in He-W 530.01(e) and He-W 546.01(e);(2) Experimental or investigational drugs, biological agents, procedures, devices, or equipment, unless authorized prior by the department;(3) Elective cosmetic surgeries or procedures;(4) Service units beyond authorized service limits, as defined in He-W 530.01;(5) Charges for missed, also known as no show, appointments or cancelled appointments;(6) Anything prohibited in He-W 500; and(7) All items or services that are considered to be part of the cost of doing business, including, but not limited:a. Time involved in completing necessary forms, claims, or reports;d. Renewing prescriptions; ande. Providing medical documents for schools, sports, and camps.(j) If a claim is paid in error, funds shall be recovered by the department or MCO through recoupment of future payments or direct billing.(k) Medicaid co-payments shall be required for services specified in He-W 570 and implemented in accordance with 42 CFR 447.52-56.N.H. Admin. Code § He-W 521.05
Derived from Number 10, Filed March 7, 2024, Proposed by #13884, Effective 2/22/2024, Expires 2/22/2034 (See Revision Note at chapter heading for He-W 500) (See also part heading for He-W 521).