N.M. Admin. Code § 8.310.10.10

Current through Register Vol. 35, No. 23, December 10, 2024

Section 8.310.10.10 - ELIGIBLE PROVIDERS AND PRACTITIONERS

A. Health care to eligible recipients in a health home is furnished by a variety of providers and provider groups. The reimbursement and billing for these services is administered by medical assistance division (MAD). Upon approval of a New Mexico provider participation agreement (PPA) by MAD or its designee, licensed practitioners, facilities and other providers of services that meet applicable requirements are eligible to be reimbursed for furnishing covered services to eligible recipients. A provider agency must be enrolled before submitting a claim for payment to the MAD claims processing contractors or the HCA contracted managed care organizations (MCOs). MAD makes available on the HCA website, on other program-specific websites, or in hard copy format, information necessary to participate in health care programs administered by MAD or its designees including program rules, billing instructions, utilization review (UR) instructions, supplements, policy, and other pertinent materials. When enrolled, a provider agency and a practitioner receive instruction on how to access these documents. It is the provider agency's and practitioner's responsibility to access these instructions, to understand the information provided and to comply with the requirements. The provider agency must contact HCA or its authorized agents to obtain answers to questions related to the material. To be eligible for reimbursement, a provider agency and practitioner must adhere to the provisions of the MAD PPA and all applicable statutes, regulations, and executive orders. MAD, its selected claims processing contractor or the MCO, issues payments to a provider agency using electronic funds transfer (EFT) only. To be eligible to receive a CareLink NM health home designation, a provider agency must hold a comprehensive community support service (CCSS) certification or attest that the agency has received all required training.

B. A provider agency must follow CareLink NM staffing requirements found in this rule and further detailed in the CareLink NM policy manual. The provider agency must agree to fulfill other responsibilities as listed in Subsection B of 8.310.10.10 NMAC. The following individuals and practitioners must be contracted or employed by the provider agency as part of its CareLink NM service delivery:

(1) A director specifically assigned to CareLink NM service oversight and administrative responsibilities.

(2) A health promotion coordinator with a bachelor's-level degree in a human or health services field and experience in developing curriculum and curriculum instruction. The health promotion coordinator manages health promotion services and resources appropriate for an eligible recipient such as interventions related to substance use prevention and cessation, nutritional counseling, or health weight management;

(3) A care coordinator who develops and oversees an eligible recipient's comprehensive care management, including the planning and coordination of all physical, behavioral, and support services. The number of care coordinators is based upon ratio in Paragraph (5) of Subsection D of 8.310.10.11 NMAC. The care coordinator:

(a) is a regulation and licensing department (RLD) licensed behavioral health practitioner; or

(b) holds a bachelor's or master's level degree and has two years of relevant healthcare experience; or

(c) is registered nurse in the state of New Mexico; or

(d) is approved through the CLNM NM health home steering committee.

(4) A community liaison who speaks a language that is utilized by a majority of non-fluent English-speaking eligible recipients, and who is experienced with the resources in the eligible recipient's local community. The community liaison identifies, connects, and engages with community services, resources, and providers. The community liaison works with an eligible recipient's care coordinator in appropriately connecting and integrating the eligible recipient to needed community services, resources, and practitioners.

(5) A supervisor who is an independently licensed behavioral health practitioner as described in 8.321.2 NMAC who supervises the care coordinator, the community liaison, the health promotion coordinator, peer and family support workers, and other optional staff that is the part of the CareLink NM multidisciplinary team. The supervisor must have direct service experience in working with both adult and child populations. Physical health and psychiatric consultants must comply with their respective licensing boards' requirements for supervision.

(6) Certified peer support worker(s) (CPSW) who hold a certification by the New Mexico credentialing board for behavioral health professionals as a certified peer support worker. The CPSW has successfully navigated their own behavioral health experiences, and is willing to assist their peers in their recovery processes.

(7) Certified family support specialist(s) who hold a certification by the New Mexico credentialing board for behavioral health professionals as a certified family support worker.

(8) A physical health consultant who is a physician licensed to practice medicine (MD) or osteopathy (DO), a licensed certified nurse practitioner (CNP), or a licensed certified nurse specialist (CNS) as described in 8.310.3 NMAC.

(9) A psychiatric consultant who is a physician (MD or DO) licensed by the board of medical examiners or board of osteopathy and is board-eligible or board-certified in psychiatry as described in 8.321.2 NMAC.

N.M. Admin. Code § 8.310.10.10

Adopted by New Mexico Register, Volume XXVII, Issue 06, March 31, 2016, eff. 4/1/2016, Amended by New Mexico Register, Volume XXIX, Issue 08, April 24, 2018, eff. 5/1/2018, Amended by New Mexico Register, Volume XXXV, Issue 15, August 13, 2024, eff. 9/1/2024