N.M. Admin. Code § 8.324.7.16

Current through Register Vol. 35, No. 17, September 10, 2024

Section 8.324.7.16 - REIMBURSEMENT

A. Transportation providers must submit claims for reimbursement on the CMS-1500 form or its successor. See 8.302.2 NMAC. Reimbursement to transportation, meal or lodging providers for covered services is made at the lesser of the following:

(1) the provider's billed charge:

(a) the billed charge must be the provider's usual and customary charge for services; for a provider with a tariff, the billed charge must be the lesser of the charges allowed by the provider's tariff or the provider's usual and customary charge.

(b) "usual and customary charge" refers to the amount an individual provider charges the general public in the majority of cases for a specific procedure or service; or

(2) the MAD fee schedule for the specific service or procedure; reimbursement by the MAD program to a transportation provider is inclusive of gross-receipts taxes and other applicable taxes; an air ambulance provider is exempt from paying gross receipts tax; therefore, the rates paid for air ambulance service do not include gross receipts tax.

B.Ground ambulance: A provider of ground ambulance services is reimbursed at the lesser of their billed charge for the service or the MAD maximum allowed amount.

(1) The MAD maximum allowed amount for transports up to 15 miles is limited to the base rate amount. The allowable base rate for advanced life support (ALS) or basic life support (BLS) includes reimbursement for the ALS or BLS equipped service, oxygen, disposable supplies and medications used in transport. The base rate reimbursement includes mileage reimbursement for the first 15 miles of transport.

(2) The allowable base rate for a scheduled non-emergency transport includes reimbursement for oxygen, disposable supplies and medications used in transport. The base rate includes mileage reimbursement for the first 15 miles of transport.

C.Air ambulance: A provider of air ambulance services is reimbursed at the lesser of billed charges or the MAD maximum allowed rate.

D.Non-emergency transportation services:

(1) A provider of non-emergency transportation is reimbursed at the lesser of their approved tariff or the MAD rate for one or multiple MAP eligible recipient transports not meeting the "additional passenger" criteria below.

(2) Reimbursement will be limited to the MAD reimbursement limitation per one-way trip for a MAP eligible recipient being transported for medical care. MAD does not provide reimbursement for any portion of the trip for which the MAP eligible recipient is not in the vehicle.

(3) An "additional passenger transport" is a non-emergency transport of two or more MAP eligible recipients who are picked up at the same location and are being transported to the same provider. Additional passenger transport services will not be covered. When more than one MAP eligible recipient is being transported from the same location to the same provider and each MAP eligible recipient has a scheduled MAD-covered medical or behavioral health appointment, MAD will allow coverage for one MAP eligible recipient.

(4) MAD covers transportation for one attendant when the MAP eligible recipient is a child 10 years of age or younger not meeting the additional passenger criteria if the medical necessity for the attendant is justified in writing by the MAP eligible recipient's medical or behavioral health provider for each transport. In cases where the MAP eligible recipient's condition is ongoing and the need for a medical attendant will not change, the attestation must be renewed every six months, unless the MAP eligible recipient who is receiving medical or behavioral health service is under 18 years of age. If the medical or behavioral health appointment is for a MAP eligible recipient 21 years of age and older, MAD does not cover transportation services or related expenses of children under 18 years of age traveling with the MAP eligible recipient.

(5) MAD covers transportation to scheduled, structured counseling and therapy sessions for a MAP eligible recipient, family, or multi-family groups, based on individualized needs as specified in the treatment plan. Claims for services are to be filed under the name of the MAP eligible recipient being primarily treated through these sessions.

N.M. Admin. Code § 8.324.7.16

8.324.7.16 NMAC - Rp, 8.324.7.16 NMAC, 1-1-14