N.M. Admin. Code § 8.324.5.16

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

Section 8.324.5.16 - REIMBURSEMENT

Once enrolled, a provider receives instructions on how to access documentation, billing, and claims processing. Reimbursement to a provider for covered services is made at the lesser of the following:

(1) the provider's billed charge; or

(2) the MAD fee schedule for the specific service or procedure.

A. The provider's billed charge must be his or her usual and customary charge for services.

B. "Usual and customary charge" refers to the amount which the individual provider charges the general public in the majority of cases for a specific procedure or service.

C.Vision appliances: A vision service provider, except an IHS facility, must submit claims for reimbursement on the CMS 1500 claim form or its successor.

D.Hearing appliances: A hearing aid or related service provider must submit claims for reimbursement on the CMS 1500 claim form or its successor. Reimbursement for hearing aids is made at the lesser of the provider's billed charge, at the cost to the billing provider as indicated by the manufacturer's, the distributor's or wholesaler's invoice, which shall not exceed MAD's maximum reimbursement limitation amounts.

(1) Reimbursement for rental of hearing aids includes the following:

(a) rental charge for hearing aid; and

(b) hearing aid mold and batteries.

(2) Rental payments apply to the allowed amount for purchase. When the rental payments equal the amount allowed for purchase, the aid is considered purchased and owned by the MAP eligible recipient.

(3) Reimbursement for repairs to hearing aids is based on the MAD fee schedule. Reimbursement for repairs to hearing aids done by a manufacturer is the lesser of the provider's billed charge or the manufacturer's charge for the repairs plus a predetermined handling fee. If complications in securing the manufacturer's repair cause the provider to incur handling costs exceeding the predetermined amount established by MAD, the billing provider can be reimbursed for actual handling costs incurred if these actual costs are adequately documented.

(4) Reimbursement is made for additional accessories and supplies, including batteries, when required. Reimbursement is made for an additional mold when a single aid type is used for both ears.

(5) Reimbursement is made for replacement ear molds.

(6) Reimbursement for insurance for hearing aid loss and accidental damage is paid at the lesser of the provider's billed charge or the maximum fee allowed by MAD. If the insurance policy cost exceeds the maximum fee established by MAD, reimbursement can be made at the actual policy rate if the actual cost is documented.

(7) Hearing appliances reimbursement limitations:

(a) Hearing aid purchase: Hearing aid purchase is limited to one monaural or binaural purchase per four year period with the following exceptions:

(i) a MAP eligible recipient under 21 years of age and is subject to prior approval;

(ii) progressive hearing loss, such as otosclerosis;

(iii) changes due to surgical procedures;

(iv) traumatic injury; and

(v) replacement of lost hearing aid in accordance with his or her insurance coverage.

(b) Dispensing fees: The hearing aid dispensing fee includes payment for the services listed below. If a binaural dispensing fee is paid, it includes payment for all services listed below for both hearing aids:

(i) hearing aid selection and the fitting of the aids;

(ii) testing of the hearing aids;

(iii) one ear mold per hearing aid;

(iv) one package of batteries per hearing aid;

(v) any other accessories required to fit the aid;

(vi) all follow-up visits and adjustments necessary for a successful fitting;

(vii) cleaning and adjustments for the life of the aid; and

(viii) shipping and handling.

(c) Hearing aid evaluation: MAD covers the evaluation of a MAP eligible recipient for the hearing aid, subject to the following limitations:

(i) the evaluation for hearing aid is not payable to the same billing provider who bills for the hearing aid dispensing fee incidental to the purchase of a hearing aid;

(ii) the evaluation for hearing aid is not payable to a billing provider under the same corporate ownership as another billing provider who bills for the hearing aid dispensing fee incidental to the purchase of the hearing aid; therefore,

(iii) physicians and audiologists can be reimbursed for audiologic and vestibular function studies in addition to a dispensing fee.

N.M. Admin. Code § 8.324.5.16

8.324.5.16 NMAC - Rp, 8.324.5.16 NMAC, 1-1-14