N.M. Admin. Code § 8.310.12.10

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

Section 8.310.12.10 - ELIGIBLE PROVIDERS

A. Health care to an eligible recipient is furnished by a variety of providers and provider groups. Reimbursement and billing for these services are administered by 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 an eligible recipient. Providers must be enrolled before submitting a claim for payment to the MAD claims processing contractor. MAD makes available on the HSD website, on other program specific websites, or in hard copy format, information necessary to participate in health care programs administered by HSD or its authorized agents, including program rules, billing instructions, utilization review instructions, and other pertinent material. When enrolled, a provider receives instruction on how to access these documents. It is the provider's responsibility to access these instructions, to understand the information provided therein and comply with the requirements. Providers must contact MAD for answers to billing questions or any of these materials. To be eligible for reimbursement, a provider must adhere to provisions of the MAD PPA and applicable statutes, regulations, rules and executive orders. MAD, or its selected claims processing contractor, issues payment to a provider using electronic funds transfer (EFT) only. Upon approval of the provider's PPA by MAD, the following practitioners and facilities may be enrolled as MAD providers:

(1) IHS facilities;

(2)Public Law 93-638 tribal facilities;

(3) urban Indian facilities (follows the rules for a federally qualified health center);

(4) IHS or tribal 638 facility pharmacies which follow 8.324.4 NMAC; and

(5) off site locations on federal land and facilities approved by MAD.

B. Practitioners contracted or employed by the above facilities are enrolled as individual providers for rendering services when appropriate.

C. Services rendered must be medically necessary and within the scope of practice of the practitioner or provider and are limited to benefits and services covered by MAD.

D. For services provided under the federal public health service, including IHS, rendering providers must meet the requirements of the public health service corp.

E. Additional provider numbers or NPI numbers may be required when necessary to assure that claiming of federal matching funds by MAD is accurate as per federal requirements to distinguish between 100% federal match rates and other match rates.

N.M. Admin. Code § 8.310.12.10

Amended by New Mexico Register, Volume XXV, Issue 20, October 30, 2014, eff. 11/1/2014