N.M. Admin. Code § 8.310.12.12

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

Section 8.310.12.12 - COVERED SERVICES

MAD covers medically necessary services and procedures for the diagnosis and treatment of an illness or injury as indicated by the eligible recipient's condition. Services must be furnished within the limits of MAD rules and within the scope of practice of the provider's professional standards. Public health services including services by public health nurses are covered to the same extent their services would be covered for non-IHS public health facilities. Limitations on covered services based on age and category of eligibility also apply to services rendered at an IHS or tribal 638 facility. Examples include enhanced benefits only available to early and periodic screening, diagnostic and treatment (EPSDT) eligible recipients, and limitations and enhanced services for alternative benefit plan (ABP) eligible recipients and eligible recipient pregnant women.

A.Outpatient encounters and visits: An outpatient encounter or visit is face-to-face contact between a practitioner and an eligible recipient as documented in the eligible recipient's physical or behavioral health record. An encounter or visit can occur at an IHS facility, tribal 638 facility, or a MAD recognized offsite location including IHS or tribal facility-based services that are provided in the home or in community centers or other locations but the medical records and the supervision or direction of the service comes from the eligible facility. To be billable as an encounter, the eligible recipient must be seen by a level of practitioner who would be eligible to be enrolled as a MAD provider or a practitioner comparable to that required by other service and provider rules or the service must be supervised by a level of practitioner who would be eligible to be enrolled as a MAD provider or a practitioner comparable to that required by other service and provider rules. Examples include but are not limited to the following: audiologist, behavioral health professional, certified nurse midwife, certified nurse practitioner, clinical nurse specialist, clinical pharmacy specialist, dentist, dental hygienist, licensed dietician, occupational therapist, optometrist, pharmacist clinician, physician assistant, physician, physical therapist, podiatrist, speech therapist and other provider types within their scope of practice as designated by MAD; see 8.310.2 NMAC, 8.310.3 NMAC and 8.321.2 NMAC.

(1) Visits to the same facility, on the same day, for the same or related diagnosis constitutes a single encounter.

(2) Multiple encounters can occur on the same date of service when the services are distinct. The following are examples of types of separate encounters:

(a) an eligible recipient receives a service that is not associated with the initial encounter and the service provided is for a different principal diagnosis; or

(b) an eligible recipient is seen at two different facilities (different provider numbers) and one of the facilities is unable to provide the necessary services for the diagnosis or treatment of the eligible recipient's condition.

(3) An outpatient encounter may be billed when a visit consists of services that could be provided in a physician's office such as instructions to a diabetic, medication management, and anticoagulant management, when provided by a qualified individual as part of a facility-based outpatient program if no other related encounter occurs that day, similar to how services would be covered for other providers and clinics in other MAD service rules.

(4) An outpatient encounter may be billed when an eligible recipient returns at a later date for a follow up MAD service such as a laboratory, radiology, or therapy service which does not require an additional physician visit if no other related visit occurs that day.

(5) When a MAD service typically requires multiple visits such as orthodontia services, crowns, and dentures, the provider may bill an amount for the initial service that includes the standard number of encounters for the service are for the standard number of visits, similar to how services would be covered for other providers in other MAD service rules, or be paid at a fee schedule amounts that closely approximates the appropriate payment for multiple services.

B.Inpatient hospital stays: An inpatient hospital stay occurs when an eligible recipient is admitted and stays overnight.

C.Services not subject to office of management and budget (OMB) codes or rates: Some services are covered by MAD when occurring within an IHS or a tribal facility but are not included or billed at the OMB rate. These services are covered to the extent described under applicable rules for the service, and include:

(1) anesthesia (professional charges);

(2) ambulatory surgical center facility services;

(3) targeted case management;

(4) hearing appliances (hearing testing is reimbursed at the OMB rate);

(5) physician inpatient hospital visits and surgeries;

(6) smoking cessation;

(7) vision appliances, including frames, lenses, dispensing, and contacts (vision exams are at the OMB rate); and

(8) telemedicine's originating site facility fee; a telemedicine originating site fee is covered when the requirements of 8.310.2 NMAC are met; both the originating and distant sites may be IHS or tribal facilities at two different locations or if the distant site is under contract to the IHS or tribal facility and would qualify to be an enrolled provider; a telemedicine originating site fee is not payable if the telemedicine technology is used to connect an employee or staff member of a facility to the eligible recipient being seen at the same facility; however, even if the service does not qualify for a telemedicine originating site fee, the use of telemedicine technology may be appropriate thereby allowing the service provided to meet the standards to qualify as an encounter by providing the equivalent of face-to-face contact.

D.Behavioral health services:

(1) Outpatient behavioral health services billed using the outpatient OMB codes include assessments and evaluations, outpatient therapies, comprehensive community support services (CCSS), and other services as approved by MAD.

(2) Other specialized behavior health services may be reimbursed at the MAD fee for service (FFS) rate or at an OMB rate, as agreed between the facility and MAD.

(3) Prior to billing specialized behavioral health services including CCSS, the IHS or tribal 638 facility must submit documentation to MAD demonstrating the ability to adhere to the service definitions and standards for the specific service; see 8.321.2 NMAC.

E.Pharmacy services: See 8.324.4 NMAC for an IHS and a tribal 638 facility enrolled as a pharmacy. Pharmacy services are not part of the OMB rate. Pharmacy claims are not limited to a 30 or 90 day supply when the prescriber has written for a larger days' supply of medication. Pharmacy claims may exceed the days' supply limitations if the amounts dispensed at one time is reasonable. IHS and tribal 638 facility pharmacy claims are not subject to formularies or preferred drug lists or authorization as the facility maintains its own formulary.

F.Transportation services: For a detailed description of transportation services, see 8.324.7 NMAC.

N.M. Admin. Code § 8.310.12.12

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