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    v1.0.28
    OpenPayerPolicy UpdatesAdministrative/Operational PolicyNew Mexico HCA EMSNC Coverage Policy Update | Open…
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    CurrentNew Mexico Health Care AuthorityPolicy N/A

    Medicaid eligibility — Emergency Medical Services for Non‑Citizens (EMSNC)

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    Governs eligibility, application, and payment responsibilities for Medicaid coverage of emergency medical services for non-citizens in New Mexico; affects applicants/recipients, providers, and local ISD offices handling EMSNC referrals and applications.

    Policy Summary
    PayerNew Mexico Health Care Authority
    PolicyMedicaid eligibility — Emergency Medical Services for Non‑Citizens (EMSNC)
    Policy CodePolicy N/A
    Change TypeNo material changes
    Effective DateFeb 1, 1995
    Last ReviewMay 1, 2020
    Next Review DateN/A
    Key ActionProviders must complete MAD 308 referral form and send decision (MAD 778) to submit claims to the Medicaid utilization review contractor.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    45 daystimeframe for Medicaid to act on applications
    Noretroactive coverage policy
    Emergency-onlyscope of covered services
    3 monthsdeadline to file application at ISD

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    Emergency Medical Services for Non-Citizens (EMSNC) — Coverage Criteria

    EMSNC coverage criteria

    Covered when ALL of the following are met:

    ALL of the following

    • Coverage is limited to bona fide emergency services and only for the duration of the emergency as determined by the Medicaid utilization review contractor.
    • Applicant files an application in person at the local county Income Support Division (ISD) office no later than the last day of the third month following the month emergency services were received.
    • Applicant brings a completed EMSNC referral for eligibility determination form (MAD 308) to the ISD office; the emergency services provider must complete the referral form.
    • Applicant provides all necessary financial and non‑financial documentation to establish eligibility; a completed and signed application form must be submitted for each request for EMSNC.
    • Medical providers may not submit eligibility applications on behalf of the applicant.
    • Medicaid must act on the application within 45 days of the date of application; if eligible, the applicant and provider are notified (NOCA to applicant; MAD 778 to provider).
    • If the application is denied or a decision is delayed beyond 45 days, the NOCA explains the reason and the applicant’s right to an administrative hearing; if denied, the applicant must notify providers.
    • There is no retroactive coverage for this category; ongoing or continuous eligibility is not created (no periodic review required; no Medicaid card is issued).
    • The applicant is financially responsible for any services not covered by Medicaid and is responsible for payment if they fail to apply promptly, verify eligibility, or notify providers of approval or denial.

    Forms, Filing Deadlines, and Code References

    Forms referencedmixed
    MAD 308Emergency medical services for non-citizens (EMSNC) referral for eligibility determination form
    MAD 778Decision for EMSNC application; form providers use to submit claims to Medicaid utilization review contractor
    Forms referenced (alternate grouping)mixed
    MAD 308Emergency medical services for non-citizens (EMSNC) referral for eligibility determination form
    MAD 778Decision for EMSNC application; form providers use to submit claims to Medicaid utilization review contractor
    Application filing deadline
    Filing deadlineNo later than the last day of the third month following the month emergency services were received
    Where to fileLocal county Income Support Division (ISD) office
    Responsible partyApplicant must file; medical providers cannot submit eligibility applications on behalf of the applicant
    Application requirementA completed and signed application form must be submitted for each EMSNC request

    Provider Responsibilities and Claims Submission

    Documentation Required

    MAD 308 completion and MAD 778 claims submission

    Providers must ensure the emergency services provider completes the MAD 308 emergency medical services for non‑citizens (EMSNC) referral for eligibility determination form and that the applicant brings the completed MAD 308 to the local ISD office; providers will receive the MAD 778 decision form and must use MAD 778 to submit claims to the Medicaid utilization review contractor for emergency review.

    • Emergency services provider completes MAD 308 referral form and applicant brings it to ISD for financial eligibility determination.
    • If application approved, provider is sent MAD 778 decision form.
    • Provider must use MAD 778 to submit claims to the Medicaid utilization review contractor for emergency review.
    Denial Risk

    Applicant files at ISD — providers must not submit applications

    Definitions and Issuing Authority

    EMSNC benefit scope
    Benefit scopeCoverage limited to emergency services only for the duration of the emergency
    Application timing impactCoverage requires timely application at ISD within the filing deadline to be considered
    No retroactive or ongoing coverageMedicaid covers only emergency services received during the specified term of the emergency; no periodic review yields continuous eligibility
    Applicant financial responsibilityApplicant is financially responsible for any services not covered by Medicaid
    Issuing agency / authority
    Issuing agencyNew Mexico Human Services Department
    Policy Summary
    PayerNew Mexico Health Care Authority
    PolicyMedicaid eligibility — Emergency Medical Services for Non‑Citizens (EMSNC)
    Policy CodePolicy N/A
    Change TypeNo material changes
    Effective DateFeb 1, 1995
    Last ReviewMay 1, 2020
    Next Review DateN/A
    Key ActionProviders must complete MAD 308 referral form and send decision (MAD 778) to submit claims to the Medicaid utilization review contractor.
    SourceLink
    On This Page
    Emergency Medical Services for Non-Citizens (EMSNC) — Coverage CriteriaForms, Filing Deadlines, and Code ReferencesProvider Responsibilities and Claims SubmissionDefinitions and Issuing Authority

    Medical providers may not file Medicaid eligibility applications on behalf of the applicant; the applicant must file the application in person at the local county ISD office no later than the last day of the third month following the month emergency services were received.

    • Application must be filed at the ISD office no later than the last day of the third month following the month the presumed emergency services were received.
    • A completed and signed application form must be submitted for each EMSNC request.
    • Applicants must provide required financial and non‑financial documentation; providers cannot substitute by filing the application.
    Federal statutory authority
    Administered under Title XIX of the Social Security Act
    State statutory authorityAdministered by the state human services department pursuant to state statute (see Section 27-2-12 et seq. NMSA 1978)