Ordering, Referring, and Prescribing Provider Enrollment
Customize your policy alerts
Sign up for New Mexico Health Care Authority Policy 15 alerts
Get alerted when Policy 15 changes without checking for updates manually.
Monitor payer policy activity
This policy requires all individual clinicians who order, refer, or prescribe Medicaid-covered services to be individually enrolled in New Mexico Medicaid; it affects individual providers (including hospital-employed, Tribal/IHS-contracted, behavioral health, pharmacists, and clinicians in FQHCs/RHCs) and payers/MCOs processing claims.
Effective October 1, 2026, all ordering, referring, or prescribing providers must be individually enrolled in Medicaid for the rendering provider to be reimbursed.
Managed Care Organizations will deny claims for services rendered by non-enrolled providers effective October 1, 2026.
Claims for services referred, ordered, or prescribed on or after October 1, 2026 by non-enrolled providers will be denied and payment cannot generally be made retroactively.
Coverage Criteria
Enrollment and claim adjudication criteria
Requirements and consequences for unenrolled referring/ordering/prescribing providers:
Applies to any clinician who orders, refers, or prescribes Medicaid-covered services.
Effective date is Oct 1, 2026.
Denied claims may be subject to recoupment by the payer.
Limited federal screening retroactivity rules may allow exceptions in specific cases.
Operational consequence includes POS denial for pharmacy claims and potential member access impacts.
Coding and Enrollment Processing
| No codes listed |
Provider Actions and Enforcement
Enrollment required by Oct 1, 2026 — claims denied for non‑enrolled ordering/referring/prescribing providers
Effective October 1, 2026, all ordering, referring, or prescribing providers must be individually enrolled in New Mexico Medicaid; claims for services referred, ordered, or prescribed on or after that date by non-enrolled providers will be denied and payment generally cannot be made retroactively. Managed Care Organizations (MCOs) are required to enforce this requirement and will deny claims for services rendered by non-enrolled providers effective October 1, 2026.
- Providers must complete individual enrollment via the Medicaid enrollment process (YesNM) before ordering, referring, or prescribing for Medicaid members on/after 10/1/2026.
- Claims that list a non-enrolled ordering/referring/prescribing provider for services on/after 10/1/2026 will be denied; payment generally cannot be made retroactively except as allowed under limited federal screening retroactivity rules.
- MCOs will apply the same denial requirement and are expected to recoup payment as appropriate for non-enrolled providers.
Definitions
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.