N.M. Admin. Code § 8.200.430.15

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

Section 8.200.430.15 - ELIGIBLE RECIPIENT RESPONSIBILITY TO GIVE PROVIDER PROPER IDENTIFICATION AND NOTICE OF ELIGIBILITY CHANGES

A. An eligible recipient is responsible for presenting a current MAP eligibility card and evidence of any other health insurance to a MAD provider each time service is requested.

(1) An eligible recipient is responsible for any financial liability incurred if he or she fails to furnish current MAP eligibility identification before the receipt of a service and as a result the provider fails to adhere to MAD rules, such as a failure to request prior approval. If this omission occurs, the settlement of claims for services is between the eligible recipient and the provider. An individual is financially responsible for services received if he or she was not eligible for MAD services on the date services are furnished.

(2) When a provider bills MAD and the claim is denied, the provider cannot bill the eligible recipient. Exceptions exist for denials caused by MAP ineligibility or by an eligible recipient's failure to furnish MAP identification in a timely manner.

(3) If an eligible recipient fails to notify the provider that he or she has received services that are limited by time or amount, the eligible recipient is responsible for payment of the service prior to rendering the service if the provider made reasonable efforts to verify whether the eligible recipient has already received services.

B. Notification of providers following retroactive eligibility determinations: If an eligibility determination is made, the eligible recipient is responsible for notifying MAD providers of this eligibility determination. When an individual receives retro MAP eligibility, the now-eligible recipient must notify all of his or her MAD providers of his or her change of eligibility. If the eligible recipient fails to notify the provider and the provider can no longer file a claim for reimbursement, the eligible recipient becomes the responsible payer for those services.

C. Notification if an eligible recipient has private insurance: If an eligible recipient is covered under a private health insurance policy or health plan, he or she is required to inform his or her MAD providers of the private health coverage, including applicable policy numbers and special claim forms.

N.M. Admin. Code § 8.200.430.15

8.200.430.15 NMAC - Rp, 8.200.430.15 NMAC, 1-1-14

Amended by New Mexico Register, Volume XXV, Issue 19, October 15, 2014, eff. 10/15/2014