COORDINATED LONG TERM SERVICES CLIENT TRANSITION OF CARE
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Policy governing continuity and transition procedures for Medicaid members enrolled in the New Mexico Coordinated Long-Term Services (CoLTS) managed care and the statewide entity (SE), including responsibilities for service continuity, prior authorizations, payment, and claims processing.
No material clinical or coverage changes in this revision.
Continuity of Coverage and Payment Responsibility
Transition coverage and payment criteria
Operational rules governing continuity of medically necessary services, payment responsibility, and claims processing during member transitions:
Prior authorizations
- For newly enrolled members, CoLTS MCO shall honor all prior authorizations granted by HSD (including SALUD! contractors) for the first 60 days of enrollment or until other arrangements are made; providers who delivered services approved by HSD shall be reimbursed by the CoLTS MCO.
- The SE shall honor all prior authorizations for 30 days or until other arrangements can be made.
- For members who recently became exempt from CoLTS, HSD shall honor prior authorizations of FFS covered benefits granted by the CoLTS MCO/SE for the first 30 days under FFS or until other arrangements are made; providers eligible and willing to enroll as FFS providers shall be reimbursed by HSD.
Prescription refills
- For newly enrolled members, the CoLTS MCO shall pay for prescription drug refills for the first 90 days or until other arrangements are made.
- The SE shall pay for all prescriptions for 30 days or until other arrangements are made; all drugs prescribed by a licensed behavioral health service provider shall be paid for by the SE.
- For members recently exempt from CoLTS, HSD shall pay for prescriptions for drug refills for the first 30 days under the FFS formulary (pharmacy must be eligible and willing to enroll as a Medicaid FFS provider).
Durable medical equipment (DME)
- The CoLTS MCO shall pay for DME costing $2,000 or more that was approved by the CoLTS MCO but delivered to the member after disenrollment from CoLTS.
- HSD shall pay for DME costing $2,000 or more approved by HSD but delivered after the member's enrollment in the CoLTS MCO; the DME provider must be eligible and willing to enroll as a Medicaid FFS provider.
- DME is not covered by the SE unless prescribed by a behavioral health service provider.
Capitation month payment responsibility
- CoLTS MCO is responsible for payment of covered physical health services for any month during which the CoLTS MCO receives a capitation payment.
- The SE is responsible for payment of covered behavioral health services for any month during which the SE receives a capitation payment.
Claims processing when contract ends
- If the CoLTS MCO/SE contract with HSD or the collaborative ends, is not renewed or is terminated, the CoLTS MCO/SE remains responsible for processing and paying claims for services delivered through the contract period but submitted after the contract end date.
- The CoLTS MCO/SE must inform service providers in writing at least 30 days prior to contract end about termination and the process for submitting claims (including contact and billing information).
- The CoLTS MCO/SE shall allow six months to process claims for services provided prior to the contract termination date and shall continue to meet established timeframes for processing all claims.
Durable Medical Equipment (DME) Thresholds
Prior Authorization and Prescription Refill Responsibilities
Honor prior authorizations during enrollment transitions
For newly enrolled members, the CoLTS MCO must honor all prior authorizations granted by the Human Services Department (HSD) through its contractors for the first 60 days of enrollment or until the CoLTS MCO has made other arrangements for the transition of services. The SE must honor all prior authorizations for 30 days or until other arrangements can be made. Providers who delivered services approved by HSD through its contractors shall be reimbursed by the CoLTS MCO; providers delivering services approved by CoLTS during the FFS period shall be reimbursed by HSD when applicable.
- CoLTS MCO honors HSD prior authorizations for first 60 days or until other arrangements are made.
- SE honors prior authorizations for 30 days or until other arrangements are made.
- Providers approved by HSD are reimbursed by the CoLTS MCO during the 60-day transition; providers approved by CoLTS are reimbursed by HSD during the 30-day FFS period when applicable.
Payment for prescription refills during transitions
For newly enrolled members, the CoLTS MCO shall pay for prescription drug refills for the first 90 days or until the CoLTS MCO has made other arrangements; the SE shall pay for all prescriptions for 30 days or until other arrangements are made. HSD shall pay for 30 days of refills for members recently exempt from CoLTS under the FFS formulary.
- CoLTS MCO pays for drug refills for first 90 days or until other arrangements.
- SE pays for all prescriptions for 30 days or until other arrangements.
- HSD pays for 30 days of refills for recently exempt members under FFS formulary.
Key Terms
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