N.M. Admin. Code § 8.310.10.11

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

Section 8.310.10.11 - PROVIDER RESPONSIBILITIES

A. A provider agency who furnishes MAD services to an eligible recipient must comply with all federal and state laws, rules, regulations, and executive orders relevant to the provision of services as specified in the MAD PPA. A provider agency also must comply with all appropriate New Mexico administrative code (NMAC) rules, billing instructions, supplements, and policy, as updated. A provider agency is also responsible for following coding manual guidelines and centers for medicare and medicaid services (CMS) national correct coding initiatives (NCCI), including not improperly unbundling or upcoding services.

B. A provider agency must verify that a recipient is eligible for a specific health care program administered by HCA and its authorized agents, and must verify the recipient's enrollment status at the time services are furnished. A provider agency must determine if an eligible recipient has other health insurance and notify HCA. A provider agency must maintain records that are sufficient to fully disclose the extent and nature of the services provided to an eligible recipient.

C. When services are billed to and paid by a MAD fee-for-service (FFS) coordinated services contractor authorized by HCA, under an administrative services contract, the provider agency must also enroll as a provider with the coordinated services contractor and follow that contractor's instructions for billing and for authorization of services; see 8.302.1 NMAC.

D. The provider agency must:

(1) demonstrate the ability to meet all data and quality reporting requirements as detailed in the CareLink NM policy manual;

(2) be approved through a HCA application and readiness process as described in the CareLink NM policy manual;

(3) have the ability to provide primary care services for all ages of eligible recipients, or have a memorandum of agreement with at least one primary care practice in the area that serves eligible recipients under 21 years of age, and one that serves eligible recipients 21 years of age and older;

(4) have established eligible recipient referral protocols with the area hospitals and residential treatment facilities;

(5) maintain the following suggested range of care coordinator staff ratios for CareLink NM eligible recipients as described in the CareLink NM policy manual:

(a) 1:51-100 for care coordination level 6;

(b) 1:30-50 for care coordination level 7;

(c) 1:50 for care coordination level 8; and

(d) 1:10 for care coordination level 9.

E. For the provider agency that renders physical health and behavioral health services, additional staff may be included; see CareLink NM policy manual for detailed descriptions.

N.M. Admin. Code § 8.310.10.11

Adopted by New Mexico Register, Volume XXVII, Issue 06, March 31, 2016, eff. 4/1/2016, Amended by New Mexico Register, Volume XXIX, Issue 08, April 24, 2018, eff. 5/1/2018, Amended by New Mexico Register, Volume XXXV, Issue 15, August 13, 2024, eff. 9/1/2024