Transportation Services and Lodging (MAD/MAP)
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Governs provider responsibilities, eligible providers, covered transportation-related services (transport, lodging, meals, attendants), prior authorization, utilization review, and reimbursement rules for New Mexico Medical Assistance Program (MAP) transportation services.
No material clinical or coverage changes in this revision.
MAD Transportation Coverage Criteria
MAD transportation coverage criteria
MAD covers transportation and related expenses when medically necessary and subject to conditions and limitations:
ALL of the following
- Provider must be enrolled and follow provider responsibilities and requirements; verify MAP recipient eligibility at time of service and check for other insurance or free alternatives (volunteers, relatives, nursing facility transport).
ALL of the following
- Covered transportation types include long distance common carriers (when recipient must leave home community), NM-certified air and ground ambulances, NMPRC-certified nonemergency vendors (taxis, vans, certain buses), transportation network companies with appropriate permit, certain exempt carriers and coordinated services contractors when enrolled.
- Lodging: covered when recipient must travel more than four hours one way and an overnight stay is required for medical necessity or cost; initial authorization up to 5 days with re-evaluation by day 5 for additional up to 15 days; re-evaluate every 15 days for extended stays.
- Meals: covered when recipient must leave home community for eight hours or more to receive services.
- Attendant coverage: MAD covers transport, meals and lodging for one attendant when medically necessary in writing or recipient is under 18; attendant for a child should be parent/legal guardian; MAD does not cover children under 18 traveling with adult recipients in most cases.
ALL of the following
- Ground ambulance: covered for emergencies certified by a physician or documented to meet emergency medical necessity criteria; non-emergency ground ambulance covered when certified as appropriate.
- Air ambulance: base rate includes non-reusable items, oxygen, professional attendants, detention/standby time and required equipment; covered consistent with emergency/medical necessity rules.
- Non-emergency transportation: covered when recipient has no primary transportation and cannot access less costly public transportation; MAD favors least costly appropriate alternatives and will not pay when other alternatives (mail delivery, free delivery) are available.
ALL of the following
- MAD will not pay for transport to non-covered services or to pharmacies (except justice-involved recipients released within 7 days), and will not reimburse for portions of trips when recipient is not in the vehicle.
- Additional passenger transports: non-emergency transport of two or more MAP recipients picked up at same location to same provider is not covered; when multiple recipients are transported, MAD will allow coverage for one recipient only unless additional passenger criteria met.
- MAD prefers free or least costly appropriate transportation alternatives (volunteers, relatives, facility-provided transport) before higher-cost options are authorized.
ALL of the following
- Out-of-state transportation and related expenses require prior authorization by MAD or its designee and are authorized only if the out-of-state service is approved; documentation must verify treatment is unavailable in New Mexico.
- Authorization for out-of-state lodging and meals can be granted for up to 30 days with re-evaluation prior to expiration and every 30 days thereafter; requests must be coordinated through MAD.
ALL of the following
- All MAD services are subject to utilization review for medical necessity and program compliance; reviews may be performed before or after services and before or after payment; certain procedures or services may require prior authorization.
- Providers must contact HCA or its authorized agents for UR instructions and follow coordinated services contractor authorization procedures when applicable.
ALL of the following
- Reimbursement is limited to the MAD reimbursement limitation per one-way trip and generally is the lesser of billed charge or MAD rate; MAD does not reimburse for trip portions when recipient not in vehicle.
- Ground and air ambulance base rates include certain supplies, oxygen and first-mile mileage provisions per reimbursement rules.
- Documentation: for long-distance travel, providers must retain written verification from referring provider justifying out-of-community travel; repeated travel requires periodic verification as specified by MAD.
Coding and Mileage Rules
| Providers must follow coding manual guidelines and CMS correct coding initiatives; avoid unbundling or upcoding. |
Prior Authorization and Utilization Review
Prior authorization and utilization review for out-of-state/out-of-community transport
Out-of-state transportation and related expenses require prior authorization by MAD or its designee; authorization is granted only if the out-of-state medical or behavioral health service is approved by MAD or its designated contractor and documentation must be available to justify travel and verify that treatment is not available in New Mexico. All MAD services are subject to utilization review for medical necessity and program compliance; reviews may occur before or after services are furnished and before or after payment. Providers must contact HCA (or its authorized agents) to request utilization review instructions, follow contractor-specific authorization procedures when services are billed to a MAD fee-for-service coordinated services contractor, and comply with UR requirements at all times.
- Requests for out-of-state transportation must be coordinated through MAD; lodging and meal authorizations for out-of-state providers can be granted up to 30 days and re-evaluated every 30 days.
- Certain procedures or services may require prior authorization from MAD or its designee; services authorized remain subject to utilization review during payment processing.
- For travel over 120 miles from the recipient's home community, transportation providers must obtain and retain written verification from the referring provider including recipient identity, the service, the out-of-community provider name, and justification that care is unavailable locally; for continued out-of-community non-emergency transportation, this information must be obtained every 12 months.
- Prior authorization does not guarantee MAD eligibility; providers must verify recipient eligibility and other insurance at time of service.
Key Definitions
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