N.M. Code R. § 8.302.4.15

Current through Register Vol. 35, No. 11, June 11, 2024

Section 8.302.4.15 - PRIOR AUTHORIZATION AND UTILIZATION REVIEW

All MAD services are subject to utilization review for medical necessity and program compliance. Reviews can be performed before services are furnished, after services are furnished, and before payment is made, or after payment is made. See 8.302.5 NMAC, Prior Authorization and Utilization Review. Once enrolled, a provider receives instructions on how to access utilization review documents necessary for prior approval and claims processing.

A. Prior authorization: Certain procedures or services can require prior approval from MAD or its designee. Services for which prior authorization was obtained remain subject to utilization review at any point in the payment process. A service provided through an out-of-state or border provider is subject to the same prior authorization and utilization review requirements, which exist for the service when not provided out-of-state.

B. Eligibility determination: Prior authorization of services does not guarantee an individual is eligible for medicaid and other health care programs. A provider must verify that an individual is eligible for a specific program at the time services are furnished and must determine if the eligible recipient has other health insurance.

C. Reconsideration: A provider who disagrees with prior authorization request denials and other review decisions can request a re-review and a re-consideration. See MAD-953 [8.350.2 NMAC], Reconsideration of Utilization Review Decisions.

N.M. Code R. § 8.302.4.15

2/1/95; 8.302.4.15 NMAC - Rn, 8 NMAC 4.MAD.704.5 & A, 8/14/08