N.M. Admin. Code § 8.313.2.20

Current through Register Vol. 36, No. 1, January 14, 2025

Section 8.313.2.20 - RESERVE BED DAYS

Medicaid pays to hold or reserve a bed for a resident of an ICF-MR for the following reasons:

1) to allow the resident to make home and community visits, e.g., vacations;

2) to adjust to a new living environment; or

3) for hospitalizations.

A. Coverage of reserve bed days: Without prior authorization, medicaid covers 65 reserve bed days per calendar year for every resident for family visits, vacations, home visits, hospitalizations and adjustment to a new living environment. Reserve bed days used under this section require documentation in the facility or the client records for all absences from the facility. If the absence from the facility is not documented in the facility or the client records, medicaid will recoup the reserve bed day payment. If the resident is away from the facility with facility staff supervision, the absence is not considered a reserve bed day.

B. Prior authorization: After the 65 days have been expended, medicaid covers, with prior authorization, an additional six reserve bed days per calendar year for discharge planning.

(1) A resident's discharge plan must clearly state the objectives, including how visits to alternative placements relate to discharge plan implementation.

(2) To obtain medicaid prior authorization, the facility must submit the following information in writing to MAD:

(a) the resident's name;

(b) social security number;

(c) requested approval dates;

(d) copy of the discharge plan;

(e) name and address of the individual who will care for the resident; and

(f) written physician order for trial placement.

(3) Documentation of the resident's absence from the facility for these six additional reserve bed days must be in the facility or the client records.

C. Documentation of reserve bed days: If residents leave the ICF-MR for any reason, documentation of the absence from the facility must be in the facility or client records. Hospitalizations must be documented in the client records at the ICF-MR.

D. Reimbursement and billing for reserve bed days: Reimbursement for reserve bed days to the ICF-MR is limited to the provider's level III rate. Billing for reserve bed days is based on the facility census, which runs from midnight to midnight. Medicaid pays for the admission day but does not pay for the discharge day. To receive payment for the additional six reserve bed days, which require prior authorization, the provider must attach a copy of the written notification of approval by MAD to the claim.

N.M. Admin. Code § 8.313.2.20

2-1-95; 8.313.2.20 NMAC - Rn, 8 NMAC 4. MAD.732.7 & A, 11-1-00; A, 5-1-07, Adopted by New Mexico Register, Volume XXXV, Issue 12, June 25, 2024, eff. 7/1/2024