N.M. Admin. Code § 8.324.10.13

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

Section 8.324.10.13 - NONCOVERED SERVICES

Ambulatory surgical center services are subject to the limitations and coverage restrictions which exist for other medicaid services. If the surgery is non-covered, the anesthesia is non-covered. See 8.301.3 NMAC, General Noncovered Services.

A. Direct payment to physician. Ambulatory surgical centers are not reimbursed by medicaid for physician fees. Reimbursement for physician fees is made directly to the provider of the service.

B. Services furnished to dual eligible recipients. By federal regulation, the medicare program pays ambulatory surgical centers only for an approved list of specific surgical procedures. Medicare is the primary payment source for individuals who are eligible for both medicare and medicaid. For these recipients, medicaid will not pay an ambulatory surgical center for a surgical procedure denied by medicare.

Ambulatory surgical centers must refer these recipients to facilities which medicare pays for the surgical procedure, such as an outpatient hospital.

N.M. Admin. Code § 8.324.10.13

2/1/95; 8.324.10.13 NMAC - Rn, 8 NMAC 4.MAD.759.4 & A, 11/1/04, Adopted by New Mexico Register, Volume XXXV, Issue 12, June 25, 2024, eff. 7/1/2024