N.M. Code R. § 8.311.5.19

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

Section 8.311.5.19 - REIMBURSEMENT

Swing bed providers must submit claims for reimbursement on the long term care turn around document (TAD) or its successor. See 8.302.2 NMAC, Billing for Medicaid Services. Once enrolled, providers receive instructions on documentation, billing, and claims processing. Swing bed hospitals are paid for high and low nursing facility routine services at the statewide average rates paid under the state plan during the previous calendar year to nursing facilities, as appropriate.

A. The following services or items are considered routine and are reimbursed as part of the routine rate:

(1) regular room;

(2) dietary and nursing services;

(3) medical and surgical supplies, including syringes, catheters, ileostomy, and colostomy supplies;

(4) use of equipment and facilities;

(5) general services, including administration of oxygen and related medications, hand feeding, incontinence care, tray service and enemas;

(6) standard items furnished routinely to all patients, such as patient gowns, water pitchers, basins and bed pans;

(7) items stocked at nursing stations in gross supply and distributed or used individually in small quantities such as cotton balls, band aids, laxatives, stool softeners, aspirin, antacids, OTC ointments and tongue depressors;

(8) reusable items expected to be available, such as ice bags, bed rails, canes, crutches, walkers, wheelchairs, traction equipment, oxygen administration equipment and other durable medical equipment;

(9) laundry services, including basic personal laundry;

(10) special dietary supplements used for tube feeding or oral feeding even if prescribed by a physician; and

(11) oxygen.

B.Ancillary services: Ancillary services are reimbursed at the same rate as outpatient services. Swing bed providers must submit claims using its hospital provider number for ancillary services on the UB-92 claim form or its successor. The reasonable costs of ancillary services for swing bed facility levels of care are determined in the same manner as for outpatient hospital services. Ancillary services are those services not considered routine, such as lab, radiology, pharmacy, and therapies.

C.Cost allocation: To allocate costs between hospital and long term care services, the total reimbursement due for all classes of long-term care recipients is subtracted from the hospital's total routine costs, before determining reimbursement for routine hospital services.

D.Medical care credits: If a recipient has income above the maintenance allowance, MAD reimburses the provider facility the difference between the allowed rate and the medical care credit. The facility is responsible for collecting the amount reported as a medical care credit.

N.M. Code R. § 8.311.5.19

2/1/95; 8.311.5.19 NMAC - Rn, 8 NMAC 4.MAD.723.10, 3/1/12