N.M. Admin. Code § 8.310.9.16

Current through Register Vol. 35, No. 23, December 10, 2024

Section 8.310.9.16 - REIMBURSEMENT

Rural health clinics must submit claims for reimbursement on the UB-92 claim form or its successor. See 8.302.2 NMAC, Billing for Medicaid Services. Once enrolled, providers receive instructions on documentation, billing, and claims processing.

A.Reimbursement for non-hospital based rural health clinics: Interim reimbursement is made at an encounter rate established for the clinic by the medicare intermediary.

(1) An "encounter" means a face-to-face meeting between a recipient and any health professional whose services are reimbursed as a covered rural health clinic service.

(2) A final cost settlement based on the audit data is made in accordance with applicable medicare regulations following the medicare cost settlement.

(3) Multiple encounters with the same or different health professional(s) that take place on the same date at a single location are considered a single encounter.

(a) Exceptions exist for cases in which the recipient suffers illness or injury requiring additional diagnosis or treatment on the same day, after the first encounter.

(b) All medical, surgical, diagnostic imaging, supplies, and clinical laboratory services furnished during the encounter are considered reimbursed within the encounter rate.

B.Reimbursement for non-core services: Reimbursement to rural health clinics for drug services, dental services, vision services, hearing services, psychiatric or psychological services, and other non-core medical services is made according to the regulations applicable to each of these specific program areas. These services are not reimbursed on a reasonable cost basis, but instead are reimbursed as described in the applicable service sections.

C.Reimbursement for hospital based rural health clinics: Interim reimbursement to hospital, or other facility, based rural health clinics is made at the percentage determined by MAD. Adjustments and fiscal year reconciliations are made by MAD.

N.M. Admin. Code § 8.310.9.16

8.310.9.16 NMAC - Rp, 8.310.3.16 NMAC, 1-1-14