CurrentNew Mexico Health Care AuthorityPolicy 8.302.2

Billing for Medicaid Services (Medicaid General Provider Policies Part 2)

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Governs billing, payment, claims filing limits, co-payment rules, provider enrollment, and related administrative responsibilities for providers furnishing services to New Mexico Medical Assistance Program (MAP) eligible recipients and managed care members.

Policy Summary

PayerNew Mexico Health Care Authority

PolicyBilling for Medicaid Services (Medicaid General Provider Policies Part 2)

Policy CodePolicy 8.302.2

Change TypeNo material changes

Effective DateOct 1, 2017

Last ReviewOct 1, 2017

Next Review Date

Key ActionProviders must be enrolled and have an approved provider participation agreement (PPA) before submitting claims and must supply EFT payment information.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

90 daysstandard claims filing limit

210 daysmax extended filing limit

2 yearsIHS/tribal finalization window

5% family income

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CurrentNew Mexico Health Care AuthorityPolicy 8.302.2

Billing for Medicaid Services (Medicaid General Provider Policies Part 2)

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Policy Summary

PayerNew Mexico Health Care Authority

PolicyBilling for Medicaid Services (Medicaid General Provider Policies Part 2)

Policy CodePolicy 8.302.2

Change TypeNo material changes

Effective DateOct 1, 2017

Last ReviewOct 1, 2017

Next Review Date

Key ActionProviders must be enrolled and have an approved provider participation agreement (PPA) before submitting claims and must supply EFT payment information.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

90 daysstandard claims filing limit

210 daysmax extended filing limit

2 yearsIHS/tribal finalization window

5% family income

max quarterly cost-sharing limit

30 daysinterest accrual period

EFT onlypayment method

Coverage, Billing, and Filing Criteria

Co-payment and billing responsibility criteria

Covered when the following co-payment applicability, exemptions, and provider billing responsibilities are met:

ALL of the following

Professional providers must collect applicable co-payments for outpatient visits and services (physicians, practitioners, clinics, urgent care, dental, outpatient therapy, behavioral health).
Providers must report co-payment amount on CMS1500/UB/pharmacy claims or corresponding electronic transactions.
Hospital providers must collect applicable co-payments for inpatient services; pharmacies must collect co-payments for dispensed drugs.
When co-payment is applied to a claim, provider shall accept MAD/MCO payment plus the applicable co-payment as payment in full.
Providers may not deny covered care or services due to an eligible recipient's or member's inability to pay the co-payment at time of service; the recipient remains liable and provider may attempt later collection or bill the recipient.

ALL of the following

A provider may not adopt a policy of waiving all MAD co-payments to promote practice or impose more than one type of co-payment for any service.
After a recipient's assistance unit reaches the maximum out-of-pocket cost sharing limit (5% of family income, calculated quarterly), the provider must reimburse any co-payments collected in excess of that limit, including when remittance advice shows the co-payment was not deducted.

Co-payment exemptions (one or more apply)

Service is a Medicare claim, Medicare Advantage claim, or follows other insurer payment (amounts apply toward primary payer deductible/co-insurance/co-payment).
Eligible recipient or member is a Native American.
Service rendered by an IHS, tribal 638, or urban Indian facility.
Service is for an eligible recipient enrolled in hospice.
Recipient is under age 21 and has only presumptive eligibility at time of service.
Maximum family out-of-pocket cost sharing limit has been reached.

ALL of the following

CHIP co-payments: $2 per prescription (includes prescription and non-prescription drug items); $5 per outpatient visit (physician/practitioner visits, therapy, behavioral health sessions); $5 per dental visit unless all services are preventive; $25 per inpatient hospital admission (unless a transfer).
Working Disabled Individual (WDI) co-payments: $3 per prescription; $7 per outpatient visit; $7 per dental visit unless preventive; $30 per inpatient hospital admission (unless a transfer).

ALL of the following

Provider must accept MAD payment as payment in full except for MAD-allowed co-payment, coinsurance, or deductible; provider may not bill remaining balance to recipient other than allowed cost sharing.
Provider cannot make recipient financially responsible when provider failed to meet timely filing or other administrative requirements; provider cannot use signed statements to shift responsibility unless allowed by MAD rules.

Claims filing and timely submission criteria

Claims filing, timely submission, grace period, resubmission, and provider responsibilities:

ALL of the following

Claims for services must be received within 90 calendar days of the date of service. Inpatient and other facility claims must be received within 90 calendar days of discharge, transfer, or otherwise leaving the facility.

Primary-payer and extended filing rules

When provider can document the claim was filed with another primary payer (including Medicare, HSD contracted MCOs, Medicare replacement plans, or another insurer), the claim must be received by MAD within 90 calendar days of the date the other payer paid or denied the claim as shown on that payer's EOB/RA, not to exceed 210 calendar days from date of service.
Providers must submit claims to the primary payer within a timeframe that reasonably allows the primary payer to process and still meet MAD timely filing limits; denials by the primary payer due to provider administrative errors must be appealed to the primary payer.

ALL of the following

MAD billing and coverage criteria

Key MAD billing and coverage rules providers must follow to receive payment:

ALL of the following

Providers must meet MAD filing limits; MAD may consider exceptions for reprocessing, other payer delays, eligibility established by hearing/court, recoupment by primary payer, IHS/tribal facility claims (two-year finalization), and certain school-based services.
See claims filing criteria for details on waiver conditions.
MAD will not process claims when federal standards for federal financial participation are not met.

ALL of the following

Providers may not bill an eligible recipient, member, or authorized representative for a service when a claim is denied due to provider filing error or failure to meet timely filing requirements.
Provider cannot bill recipients for office administrative tasks (billing claims, checking eligibility, making referral calls) or turn accounts to collections after being informed of recipient MAP eligibility; if account was turned over, provider must retrieve it.

Coding, Units, and Related Rules

Timed service codingmixed

CPT/HCPCS timed units

Billing of 15-minute or hourly units must follow CPT/HCPCS instructions and the provided time-to-units rounding chart

Anesthesiamixed

Anesthesia billing

Anesthesia units billed per 8.310.3 NMAC

Rendering provider identificationmixed

No codes listed

inv-07: Minimum billable time

Minimum billable time ruleServices that are in their entirety less than 8 minutes cannot be billed as one 15‑minute unit; follow the time-to-units rounding chart for CPT/HCPCS timed codes.

Rounding intervals8 through 22 minutes = 1 unit; 23 through 37 minutes = 2 units; 38 through 52 minutes = 3 units (and so on per the chart).

Reporting responsibilityProviders must correctly report service units and follow CPT/HCPCS instructions for time-based codes.

inv-08: Interest accrual period

Interest accrual periodInterest accrues from the date of final determination and is charged on overpayments (or paid on underpayments) for each 30 calendar‑day period that payment is delayed.

Provider Enrollment, Billing Steps, and Actionable Requirements

Billing Rule

Enroll and provide EFT payment information before billing

Providers must be enrolled and have an approved MAD provider participation agreement (PPA) before submitting any claim for payment to the MAD claims processing contractors. MAD issues payments by electronic funds transfer (EFT) only; providers must supply the necessary payment information to receive EFT payments.

Provider must be enrolled and PPA approved prior to claim submission.
MAD or its selected claims processing contractor issues payments using EFT only; providers must supply necessary information for payment.

Billing Rule

Accurately report timed CPT/HCPCS units (direct patient-contact only)

Report service units exactly as required by CPT/HCPCS instructions. For time-based CPT/HCPCS codes billed as 15‑minute or hourly units, follow the policy rounding/chart rules; services under eight minutes may not be billed as a 15‑minute unit. Only the direct patient-contact time that counts toward the CPT/HCPCS timed unit should be reported.

Key Definitions

inv-14: authorized representative

Who may serve as authorized representativeAn individual designated in writing by the eligible recipient or member; may include an attorney, a person acting under a valid power of attorney, a guardian, or other named individual(s).

Scope of authorityAuthorized representative is designated to represent and act on behalf of the eligible recipient or member and access identified case information for a specified purpose and time frame.

Documentation requiredFormal documentation authorizing the named individual(s) to access case information for the specified purpose and time frame must be provided by the member or authorized representative.

inv-15: eligible recipient

DefinitionAn eligible recipient is an individual who has met a Medical Assistance Program (MAP) category of eligibility and receives MAD services through the fee-for-service (FFS) program.

Policy Summary

PayerNew Mexico Health Care Authority

PolicyBilling for Medicaid Services (Medicaid General Provider Policies Part 2)

Policy CodePolicy 8.302.2

Change TypeNo material changes

Effective DateOct 1, 2017

Last ReviewOct 1, 2017

Next Review Date

Key ActionProviders must be enrolled and have an approved provider participation agreement (PPA) before submitting claims and must supply EFT payment information.

SourceLink

On This Page

Service was rendered prior to any eligibility being established (including when eligibility is later established retroactively).

Eligible recipient or member is in foster care or has an adoption category of eligibility.

Eligible recipient or member resides in a nursing facility, facility for individuals with intellectual disabilities, or receives waiver/residential care or home and community-based services waiver.

Service is not for a MAD category of eligibility (e.g., certain DOH children's medical services).

Service is a provider-preventable condition or solely to treat a provider-preventable condition.

Eligible recipient, member, or service is otherwise exempt as described in MAD rules (including family planning, preventive services, prenatal/postpartum care where specified).

If a claim or part of a claim is returned, denied, or paid incorrectly but was submitted within the initial timely filing period, the provider has a one-time 90-calendar-day grace period (from the remittance advice or return notice date) to resubmit the claim or an adjustment; additional 90-day grace periods are not allowed. Providers may continue to resubmit during that grace period.

ALL of the following

The provider is responsible for submitting claims timely, tracking claim status, following up on transmissions, and re-filing missing claims within filing limits. Filing limits are not waived for provider administrative shortcomings (inadequate understanding, insufficient staff, failure to track).
Adjustments or requests for additional payment must be received in MAD-approved adjustment format with necessary explanations and information within the one-time 90-day grace period.

Circumstances where MAD may waive filing limits

MAD may waive filing limits when an error or delay by MAD or its contractor prevented timely filing, considering provider efforts to file and follow up.
When the claim was filed within the filing limit but is being reprocessed or adjusted for issues not related to filing limits.
When another payer or responsible party could not or did not process the claim timely or provide necessary information; waiver consideration includes provider's follow-up efforts.
When eligibility was established by hearing, appeal, or court order; MAD will consider provider efforts to file timely after such determination.
Claims from federal IHS or PL 93-638 tribal facilities must be finalized within two years of date of service.
MAD school-based services provided under an IEP or IFSP have an initial 90-calendar-day filing limit applied.

ALL of the following

For recipients also entitled to Medicare, providers must first bill the appropriate Medicare payer. After Medicare payment, MAD pays amounts for coinsurance, co-payment, and deductible subject to MAD reimbursement limits.
If Medicare payment exceeds the MAD allowed amount for the service, no further payment is made and the provider may not collect the remainder from the recipient; providers must accept assignment on Medicare claims for MAD recipients. Providers who do not participate in Medicare must inform recipients and obtain consent prior to billing them when Medicare cannot pay due to provider choices.
Special Medicare Part B behavioral health 'psych reduction' adjustment: MAD may pay coinsurance/deductible to allow provider to receive 80% of Medicare allowed amount where applicable.

ALL of the following

MAD pays providers who actually rendered services; certain providers may be reimbursed at encounter or all-inclusive rates that include contracted services (e.g., NF, ICF-IID, residential treatment centers, group homes, hospice, FQHC, RHC, IHS/tribal 638). Other contracted services require written prior approval from MAD or its designee.
Billed rates for contracted services must reflect direct and indirect costs plus reasonable administrative charge.

ALL of the following

MAD does not pay collection agencies (factors) directly; no reimbursement for discharge day in institutional settings; no payment for wrong patient/body part/incorrect procedure; payments for acquired conditions may be denied or limited.
Interest on overpayments and underpayments accrues from final determination; interest is charged/paid for each 30-calendar-day period payment is delayed; MAD may waive interest in limited circumstances (e.g., liquidation within 30 days or administrative cost considerations).

ALL of the following

If a provider receives payment from another source after MAD payment, the provider must remit to MAD the lower of the insurance payment or the amount paid by MAD, properly identifying the claim. Providers must return overpayments to MAD as directed. Filing limits do not apply when returning overpayments.

Definition of final determinationFinal determination occurs when MAD, its claims processor, or audit contractor issues a written demand/determination, or when a timely‑filed cost report shows an amount due not included with the report.

Single extensionA one‑time extension of up to 30 calendar days may be granted for filing an unfiled cost report for good cause with written approval prior to the due date.

Follow CPT/HCPCS instructions for units tied to time.
When billing 15‑minute or hourly units, use the provided time-to-units chart; time less than 8 minutes yields zero 15‑minute units.

Prior Authorization

Request filing-limit waivers only for specified circumstances

MAD may waive timely filing limits in specified situations; providers should request a waiver only when one of the enumerated conditions applies and be prepared to document efforts to file timely. Waiver situations include MAD or contractor error/delay, claims being reprocessed, delays by another payer, eligibility established by hearing/appeal/court, IHS/PL 93-638 tribal facility claims finalized within two years, and certain MAD school-based IEP/IFSP claims.

Waivers considered for MAD/contractor error or delay, with review of provider's initial filing and follow-up efforts.
Waivers considered when another payer delayed processing or when eligibility established by hearing/appeal/court.
IHS/PL 93-638 tribal facility claims must be finalized within two years to qualify.
MAD school-based services to IEP/IFSP recipients have a 90‑day initial filing limit context for waivers.

Prior Authorization

Get written prior approval for contracted services when required

Obtain written prior approval from MAD or MAD’s designee before billing for contracted services that are not otherwise payable; MAD only makes payment to a provider who actually rendered the services and reimburses encounter-rate or approved providers as specified. Providers must follow MAD direction on submission to coordinated service contractors when applicable.

MAD pays only providers who actually rendered services; some contracted services are built into encounter/all‑inclusive rates.
Submit claims to the appropriate coordinated service contractor as directed by MAD.
Obtain written prior approval from MAD or its designee when required before providing/billing contracted services.

Billing Rule

Bill Medicare first and submit Medicare EOBs for crossovers

For dually eligible recipients, bill Medicare first; if claims do not cross over automatically, submit the Medicare payment and Medicare explanation of benefits (EOB) to the MAD claims processing contractor and meet MAD filing limits. Providers must inform recipients about Medicare assignment and may not bill dually eligible recipients for services Medicare cannot pay due to provider non‑participation without the recipient’s expressed consent.

Bill Medicare first for dual-eligible recipients; supply Medicare EOB and payment information when crossover fails.
Providers must meet MAD filing limits when submitting crossover claims.
Providers cannot bill a dually eligible recipient for services Medicare cannot pay because the provider does not participate in Medicare, or because the provider refuses to accept assignment, without the recipient’s expressed consent.

Applies to individuals enrolled and served under MAD's fee‑for‑service delivery (not MCO members).

Implication for billingProviders billing MAD for FFS recipients must verify MAP eligibility before submitting claims under the FFS program.

inv-16: member

DefinitionMember means a MAP eligible recipient who receives his or her MAD services through a HSD‑contracted managed care organization (MCO).

Distinction from eligible recipient'Member' denotes recipients served via an MCO rather than the fee‑for‑service program.

Billing implicationBilling and service authorization rules for members are governed by the recipient's MCO contract and MAD guidance for managed care arrangements.

inv-17: co-payment

Co-payment definedA co‑payment is a fixed dollar amount that a Medicaid recipient must pay directly to a provider for a service, visit, or item.

Timing of collectionA co‑payment is to be charged at the time of service or receipt of the item.

Provider responsibilitiesProviders must collect and report co‑payments but must follow MAD exemptions and cannot deny services solely for inability to pay at time of service where MAD rules apply.

inv-18: Claim crossover

Claim crossover explainedA 'cross‑over claim' is payment information sent directly from Medicare to the MAD claims processing contractor when Medicare can identify the individual as an eligible recipient or member.

Provider action when crossover failsIf claims fail to crossover automatically, the provider must bill the appropriate MAD claims processing contractor directly and supply Medicare payment and EOB information while meeting MAD filing limits.

Medicare-first requirementProviders must first bill the appropriate Medicare payer for dually eligible recipients; MAD pays applicable coinsurance/deductible subject to MAD limits.

inv-19: Contracted practitioner billing

Billing provider vs rendering providerMAD only makes payment to a provider who actually rendered the services; when practitioners are contracted, billing must reflect the provider who rendered the service or conform to specified contracted exceptions.

Rendering provider identificationPractitioners who render services must be listed as the rendering provider and appropriate application/enrollment information must be completed as required by MAD.

Contracted services exceptionsCertain providers may be reimbursed at encounter or all‑inclusive rates that incorporate contracted services (e.g., NF, ICF‑IDD, residential treatment centers, hospice, FQHC, RHC, IHS/tribal 638 facilities); otherwise written prior approval is required for contracted services not specified.