N.M. Admin. Code § 8.310.10.15

Current through Register Vol. 35, No. 21, November 5, 2024

Section 8.310.10.15 - PRIOR AUTHORIZATION (PA) AND UTILIZATION REVIEW (UR)

All MAD services are subject to utilization review (UR) for medical necessity and program compliance. Reviews can be performed before services are furnished, after services are furnished, before payment is made, or after payment is made. The provider agency must contact MAD or its designees to request UR instructions. It is the provider agency's responsibility to access these instructions or ask for hard copies to be provided, to understand the information provided, to comply with the requirements, and to obtain answers to questions not covered by these materials. When services are billed to and paid by a coordinated services contractor authorized by HCA, the provider agency and practitioner must follow that contractor's instructions for authorization of services. A provider agency and practitioner rendering services to a member must comply with that MCO's prior authorization requirements.

A.Prior authorization: CareLink NM services do not require prior authorization, but are provided as approved by the CareLink provider agency. However, other procedures or services may require a prior authorization from MAD or its designee. Services for which a prior authorization is required remain subject to UR at any point in the payment process, including after payment has been made. It is the provider agency's responsibility to contact MAD or its designee and review documents and instructions available from MAD or its designee to determine when a prior authorization is necessary.

B.Timing of UR: A UR may be performed at any time during the service, payment, or post payment processes. In signing the MAD PPA, a provider agency agrees to cooperate fully with MAD or its designee in its performance of any review and agrees to comply with all review requirements. The following are examples of the reviews that may be performed:

(1) prior authorization review (review occurs before the service is furnished);

(2) concurrent review (review occurs while service is being furnished);

(3) pre-payment review (claims review occurring after service is furnished but before payment);

(4) retrospective review (review occurs after payment is made); and

(5) one or more reviews may be used by MAD to assess the medical necessity and program compliance of any service.

C.Denial of payment: If a service or procedure is not medically necessary or not a covered MAD service, MAD may deny a provider agency's claim for payment. If MAD determines that a service is not medically necessary before the claim payment, the claim is denied. If this determination is made after payment, the payment amount is subject to recoupment or repayment.

D.Review of decisions: A provider agency that disagrees with a prior authorization request denial or another review decision may request reconsideration from MAD or the MAD designee that performed the initial review and issued the initial decision; see 8.350.2 NMAC. A provider agency that is not satisfied with the reconsideration determination may request a HCA provider administrative hearing; see 8.352.3 NMAC. A provider agency that disagrees with the member's MCO decision is to follow the process detailed in 8.308.15 NMAC.

N.M. Admin. Code § 8.310.10.15

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