N.M. Admin. Code § 8.320.6.12

Current through Register Vol. 35, No. 17, September 10, 2024

Section 8.320.6.12 - PROVIDER RESPONSIBILITIES

A.General responsibilities:

(1) A provider who furnishes services to an eligible recipient must comply with all terms and conditions of his or her MAD PPA and the MAD New Mexico administrative code (NMAC) rules.

(2) A provider must verify that an individual is an eligible recipient at the time services are billed.

(3) A provider must appoint a program liaison and backup alternate for each LEA, REC or other SFEA, who will be responsible for receiving and disbursing all communication, information and guidelines from HSD regarding the MAD school-based services program, including information on, but not limited to, direct services and administrative claiming.

B.Documentation requirements:

(1) A provider must maintain all records necessary to fully disclose the nature, quality, amount and medical necessity of services billed to a MAP eligible recipient who is currently receiving MAD services or has received MAD school-based services in the past that are or were part of the eligible recipient's IEP, IFSP, 504 plan, IHCP or other care plan. Payment for services billed to MAD that are not substantiated in the eligible recipient's records are subject to recoupment. Documentation must be retained for at least six years from the date of payment or until ongoing audit issues are resolved, whichever is longer; see 8.302.2 NMAC.

(2) For services covered under this rule, complete copies of the eligible recipient's IEP, IFSP, 504 plan, IHCP or other care plan with the individualized treatment plan (ITP) portions of the IEP, IFSP, 504 plan, IHCP or other care plan must be maintained as part of the required records. Those records must clearly indicate that the MAD school-based service is a part of the eligible recipient's IEP, IFSP, 504 plan, IHCP or other care plan.

(3) Documents in the MAP eligible recipient's file must include:

(a) the IEP, IFSP, 504 plan, IHCP or other care plan with the ITP;

(b) evaluation performed by the provider or the annual and current present level of performance or other determination of medical necessity;

(c) annual PCP notification or documentation of a good faith effort for services provided through an IEP/IFSP;

(d) treatment notes that relate directly to the IEP, IFSP, 504 plan, IHCP or other care plan goals and objectives specific to each MAP eligible recipient; and

(e) billing information recorded in units of time; see 8.302.2 NMAC.

C.Record availability: The provider must upon request promptly furnish to HSD, the secretary of the federal department of health and human services, or the state medicaid fraud control unit any information required in this rule, including the eligible recipient and employee records, and any information regarding payments claimed by the provider furnishing services. Failure to provide records on request may result in a denial of claims.

N.M. Admin. Code § 8.320.6.12

8.320.6.12 NMAC - Rp, 8.320.6.11 NMAC, 1-1-14, Adopted by New Mexico Register, Volume XXVI, Issue 12, June 30, 2015, eff. 7/1/2015, Amended by New Mexico Register, Volume XXXIII, Issue 12, June 21, 2022, eff. 7/1/2022