N.M. Code R. § 8.311.5.15

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

Section 8.311.5.15 - PRIOR APPROVAL AND UTILIZATION REVIEW

All medicaid 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, providers receive instructions and documentation forms necessary for prior approval and claims processing.

A.Prior approval: All utilization review activities, including level of care determinations and length of stay assignments for recipients at a nursing facility are carried out according to established MAD policy. All physical therapy, occupational therapy, and speech therapy furnished to inpatients in swing bed facilities at a high or low level require prior approval. Services for which prior approval was obtained remain subject to utilization review at any point in the payment process.

B.Eligibility determination: Prior approval of services does not guarantee that individuals are eligible for medicaid. Providers must verify that individuals are eligible for medicaid at the time services are furnished and determine if medicaid recipients have other health insurance.

C.Reconsideration: Providers who disagree with prior approval request denials and other review decisions can request a re-review and a reconsideration. See Section MAD-953, Reconsideration of Utilization Review Decisions.

N.M. Code R. § 8.311.5.15

2/1/95; 8.311.5.15 NMAC - Rn, 8 NMAC 4.MAD.723.6, 3/1/12