N.M. Admin. Code § 8.310.2.11

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

Section 8.310.2.11 - SERVICE LIMITATIONS AND RESTRICTIONS

MAD covers the following services with the frequency limits indicated. For purpose of this rule, a provider is considered part of the same provider group if he or she practices in the same office or clinic or has direct access to the MAP eligible recipient's medical or behavioral health records. Exceeding these limits requires prior authorization.

A.Office visits in a practitioner's office: Visits are limited to one-per-day from the same provider or provider group, unless the claim documents a change in the MAP eligible recipient's condition that could not have been anticipated at the first visit.

B.Physical medicine modalities in a professional practitioner's office: These modalities are limited to three-per-month. The limit is met when the same modality is performed three times during a calendar month, when three different modalities are performed during a month, or when three different modalities are performed during one visit.

C.Physical medicine procedures and kinetic activities in a professional practitioner's office: These services are limited to three-per-month from the same provider or provider group. The limit is met when the same procedure is performed three times during a calendar month, when three different procedures are performed during a month, or when three procedures are performed during one visit.

D.Manipulation, osteo-manipulative therapy, or myofacial release in a professional practitioner's office: These services are limited to three manipulations per calendar month, regardless of the area or areas manipulated. The limit is met when a manipulation of three different areas or of the same area at three different visits is performed during a month.

E.Medically necessary services: All services are limited to those that are medically necessary, including the length of time and the frequency of service.

N.M. Admin. Code § 8.310.2.11

8.310.2.11 NMAC - Rp, 8.310.2.13 NMAC, 1-1-14