N.M. Admin. Code § 8.310.12.15

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

Section 8.310.12.15 - REIMBURSEMENT

OMB rates are published annually in the federal register and are applicable to an IHS and a tribal 638 facility. These rates are applied retroactively to their effective date.

A. IHS OMB outpatient and inpatient reimbursement rates include facility fees and professional fees except as described in this rule.

(1) Outpatient encounters and visits: MAD reimburses outpatient encounters and visits at the OMB outpatient encounter rate. Reimbursement at OMB rates is retroactive to the dates of service for which the OMB rates are applicable.

(2) Inpatient hospital service: MAD reimburses covered inpatient hospital stays at the federally published OMB hospital inpatient per diem rate. The inpatient OMB rate applies when an eligible recipient has been under outpatient care observation or is receiving extended outpatient medical services, and the time period has been for 24 hours or more whether the eligible recipient has been formally admitted or not. Risk factors such as distance of the facility from the eligible recipient's residence for potential emergency follow up care, as well as lack of availability of step-down care providers (home health services, nursing facilities, and acute long term care hospital facilities) may be considered in making discharge decisions regarding the eligible recipient. Alternatively, the facility may elect to bill a daily outpatient OMB rate for an eligible recipient under observation. Reimbursement at OMB rates is retroactive to the date of service for which the federal OMB rates are applicable.

(3) Reimbursement following medicare payment is made at the full copayment, deductible and co-insurance amounts determined by medicare. Reimbursement following payment by other insurance is made at the OMB rate, is applicable, less the payment received from the other insurer.

B. Services not subject to the OMB rates are reimbursed according to MAD rules for the specific service. For services not reimbursable the facility at 100% federal matching funds, the facility may be enrolled additionally for services to be paid at standard federal matching rates.

C.Electronic billing requirements: Electronic billing of claims is required unless an exemption has been allowed by MAD. Exemptions will be given on a case-by-case basis with consideration given to barriers faced by the provider in electronic billing, such as small volume for which developing electronic submission capability is impractical. The requirement for electronic submission of claims does not apply when paper attachments must accompany the claim form.

D.Responsibility for claims: A provider is responsible for all claims submitted under his or her national provider identifier (NPI) or provider number, including responsibility for accurate coding representing the services provided without inappropriately upcoding, unbundling, or billing mutually exclusive codes as indicated by published coding manuals, directives, CMS correct coding initiatives, and NMAC MAD rules.

N.M. Admin. Code § 8.310.12.15

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