N.M. Admin. Code § 8.301.5.11

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

Section 8.301.5.11 - IDENTIFICATION OF CANDIDATES

All medicaid recipients are potential candidates for inclusion in medical management, whether enrolled in Salud! or covered under medicaid fee-for-service.

Recipients are identified as candidates for review by HCA, the MCO, a provider or other appropriate entities. The following situations may indicate a need for medical management:

A. individuals who overutilize medical services;

B. individuals who are habitually non-compliant and miss appointments, or who frequently seek unauthorized treatment or care; and

C. individuals who frequently change PCPs or simultaneously utilize multiple pharmacy providers;

D. individuals who regularly utilize emergency room services for inappropriate, nonemergency care.

N.M. Admin. Code § 8.301.5.11

2-1-95; 8.301.5.11 NMAC - Rn, 8 NMAC 4.MAD.604.2 & A, 7-1-01, Adopted by New Mexico Register, Volume XXXV, Issue 12, June 25, 2024, eff. 7/1/2024