CurrentNew Mexico Health Care AuthorityPolicy N/A
Specialized behavioral health provider enrollment and reimbursement
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State rules governing enrollment, eligibility, coverage, supervision, utilization review, prior authorization, and reimbursement for specialized behavioral health services provided to New Mexico Medicaid (MAP) recipients.
Policy Summary
PayerNew Mexico Health Care Authority
PolicySpecialized behavioral health provider enrollment and reimbursement
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateAug 10, 2021
Last ReviewAug 10, 2021
Next Review DateN/A
Key ActionPrior authorization is not required for up to five days for eligible recipients meeting ASAM level three criteria; obtain prior authorization for continued care beyond five days.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
PermanentDuration of rule
2021-08-10Effective date
Up to 5 daysAARTC immediate admission without prior auth
24-hour care requiredAARTC staffing expectation
>16 beds / 22-64IMD age exclusion
Coverage criteria for specialized behavioral health services
AARTC coverage criteria
Coverage and facility eligibility for Adult Accredited Residential Treatment Centers (AARTC) for recipients 18 and older with SUD meeting ASAM level three criteria.
ALL of the following
- Must be accredited by The Joint Commission (JC), CARF, or COA as an adult (18+) residential treatment facility; must be certified through BHSD application process and hold required supervisory certificate; out-of-state/MAD-border AARTCs must be accredited and licensed in their state.
Refs detail accreditation, certification and out-of-state requirements.
ALL of the following
- Treatment must meet ASAM level three service requirements for admitted sub-levels and be provided under direction of an independently licensed clinician/practitioner; facility must provide 24-hour care with trained staff and provide MAT when indicated; practitioners trained in ASAM principles.24-hour care
See ASAM sub-level staffing details and WM length-of-stay guidance.
ALL of the following
- Must perform diagnostic evaluation and necessary psychological testing (avoid repeat evaluations), regularly scheduled individual/family/group counseling per ASAM guidelines, age-appropriate life skills development, medical management, crisis intervention, professional consultation and non-medical transportation as routine residential services.
Routine services reimbursed under AARTC rate; room and board and certain external medical services billed separately.
ALL of the following
- Treatment plan must be developed by a team of professionals in consultation with the recipient consistent with ASAM and accreditation standards; interdisciplinary team must review the treatment plan at least every 15 days.review every 15 days
ALL of the following
- Prior authorization is not required for up to five days to facilitate immediate admission for eligible recipients meeting ASAM level three; within that period provider must notify MAD of admission; if continued care beyond five days is needed, prior authorization must be obtained from MAD or its designee; out-of-state AARTCs require prior authorization prior to admission.
Services for which prior authorization was obtained remain subject to utilization review.
ALL of the following
- AARTC agencies must submit claims on UB-04 (or successor); MAD reimbursement covers routine residential services but not room and board; detailed billing instructions in BH policy and billing manual.
Vacancy/therapeutic leave factors and cost-report requirements referenced for ARTC/ARTC-like rates.
ALL of the following
- AARTC services subject to general MAD non-covered restrictions (e.g., services without prior approval when required, services to ineligible individuals, formal educational/vocational services, activity therapy/milieu therapy when listed as non-covered).
ALL of the following
- AARTC must meet ASAM level three criteria for admissions; ASAM withdrawal management sublevels (3.2WM typical 3-5 days; 3.7WM up to 7 days) and staffing/monitoring expectations apply when WM services provided within the facility.
General behavioral health coverage
General coverage and non-covered services for specialized behavioral health.
ALL of the following
- All behavioral health services must meet MAD's definition of medical necessity (8.302.1 NMAC); rendering practitioners must be enrolled as MAD providers and practice within their licensed scope; when services are performed by supervised practitioners supervision cannot be billed separately.
Providers receive enrollment instructions and billing access upon enrollment.
ALL of the following
- MAD reimburses at the lesser of the MAD fee schedule or provider's billed charge; special federal/facility-specific payment rules apply for IHS, tribal, FQHCs, RHCs following federal guidelines.
See BH policy and billing manual for detailed reimbursement procedures.
ALL of the following
- The following are not MAD covered benefits: hypnotherapy, biofeedback, services not meeting medical necessity, educational or vocational services related to traditional academics or vocational training, experimental/investigational procedures, activity/ recreational therapy, electroconvulsive therapy, services outside license scope, treatment of intellectual disabilities alone, services requiring prior authorization when not obtained, milieu therapy, and other items listed in Subsection G and related NMAC rules.
ALL of the following
- Behavioral health services cannot be delegated to providers not licensed for independent practice except as specified; a behavioral health provider cannot bill as rendering provider for services they supervised if performed in part or wholly by another individual; supervision is not billable separately.
Coverage criteria for WM, ARTC, ABA, ACT
Coverage conditions, eligible providers, required services, and non-covered items for WM, ARTC, ABA, and ACT.
ALL of the following
- WM levels include ASAM 3.2WM (clinically-managed residential WM; typically 3-5 days) and ASAM 3.7WM (medically-monitored; up to 7 days); services require interdisciplinary staffing per ASAM and facility protocols for escalation if condition deteriorates.
ALL of the following
- Treatment plan must be developed by team of professionals in consultation with recipient and reviewed at least every 15 days; prior authorization is not required for up to five days for eligible recipients meeting ASAM level three criteria, but provider must notify MAD and seek prior authorization if continued care beyond five days is needed.
ALL of the following
- ARTC must be accredited (JC/COA/CARF), certified via BHSD process, have written policies using ASAM level three criteria, meet ASAM treatment requirements, provide MAT as indicated, and ensure practitioners trained in ASAM principles; covered services include diagnostic evaluation, psychological testing, regularly scheduled counseling/therapy, life skills development and 24-hour staffed care.
ALL of the following
- ARTC treatment plans must be developed within 14 calendar days of admission and reviewed at least every 30 days; ARTCs submit UB-04 claims; routine residential services included in rate while pharmacy/primary care/labs billed separately; vacancy factor of 24 days built into ARTC/ARTC-like rates.
ALL of the following
- ABA uses three stages: stage 1 (AEP completes comprehensive diagnostic evaluation and ISP), stage 2 (BA completes behavior/functional analytic assessment and treatment plan), stage 3 (treatment implemented by BA/BAA/BT with clinical management and supervision); eligible providers include AEPs, BAs, BAA/BCaBA, and BTs with enrollment and background checks required.
ALL of the following
- Most stage three ABA services require prior authorization renewed every six months and must include documentation (CDE/ISP, proposed model/hours, supervision and clinical management hours if exceeding thresholds, and other ISP services); non-covered: services not based on ABA principles, activities that supplant school IEP/IFSP educational services, non-ABA therapeutic services, staff training or certification costs.
ALL of the following
- ACT agencies must maintain an HSD ACT approval letter, operate fidelity-model teams of approximately 10-12 members (waivers possible), provide 24/7 services, and include required roles (team leader, medical director/prescriber, nurses, licensed behavioral health staff, employment specialist, CPSW, administrative staff); medically necessary ACT services covered include face-to-face, collateral, assertive outreach (limited to 5% of monthly individual service time), and group encounters per model.
Program coverage nodes
Coverage determinations, eligible populations, and service descriptions for specified programs.
ALL of the following
- Medically necessary ACT services covered for eligible recipients 18+ with SMI (and 15-30 in first two years of first-episode psychosis); services include face-to-face, collateral, assertive outreach (<=5% per individual of monthly service time), and group encounters (basic living skills, psychosocial skills training, peer groups, wellness/recovery groups).
ALL of the following
- MAD does not cover other psychiatric, non-intensive outpatient substance abuse or crisis services billed with ACT except for medically necessary medications and hospitalizations; PSR may be billed for up to six months for transitions when included in the treatment plan; agencies must comply with ACT fidelity and have BHSD approval for adaptations.
ALL of the following
- Validated high-risk screenings are covered; a treat-first model may be billed provisionally for up to four encounters with provisional diagnosis—after four encounters a diagnostic evaluation is required (refer to BH policy/billing manual for specifics).
ALL of the following
- Respite is short-term direct care supervision for caregivers, deliverable in-home or other settings; eligible for members up to 21 with SED or youth in protective custody; subject to limits and exclusions and prior authorization if exceeding 30 days/720 hours per year.
ALL of the following
- BMS covered as EPSDT for recipients under 21 when identified via screening/evaluation; provided by CYFD-certified agencies and delivered as part of an integrated treatment plan to avoid hospitalization/residential placement; worker supervision and 30-day review cycles apply.
ALL of the following
- CET covered for adults 18+ with cognitive impairment associated with specified SMIs or autism; requires BHSD approval and fidelity to the evidence-based model; core CET services bundled (up to 3 hrs group + 1 hr individual), medications and other therapies billed separately; agency submits CMS-1500 claims.
ALL of the following
- CCSS covered to coordinate culturally sensitive recovery-oriented services; providers must complete state CCSS training and attest when adding specialty service code; clinical services/supervision by licensed practitioners per licensing regulations; case notes must identify activities, locations, duration and relation to CCSS treatment plan/goals.
Crisis stabilization coverage criteria
Crisis stabilization (crisis triage) services — who is eligible and what is covered or excluded
ALL of the following
- Adult crisis triage centers serve adults 18+ (youth 14-17 may be served by youth-designated centers); recipients with co-occurring diagnoses are eligible; services cannot be refused solely due to law enforcement hold or conditional release status.
ALL of the following
- Comprehensive history and physical at admission; assessment and plan development; crisis triage, screening/assessment, de-escalation, brief intervention, psychological counseling, peer support; ambulatory withdrawal management (ASAM 2.1) and clinically/medically monitored residential WM per ASAM 3.7 when included; prescribing/administration of medication; lab/toxicology testing; navigational services (transportation, housing, prescriptions, referrals).
ALL of the following
- Acute medical alcohol detoxification requiring hospitalization and medical care beyond basic first aid/CPR are non-covered in crisis triage; other general MAD non-covered restrictions apply (see 8.310.2 and 8.321.2 NMAC).
ALL of the following
- Crisis triage services do not require prior authorization; however other procedures/services (e.g., inpatient admission) may require prior authorization; all MAD services are subject to utilization review and providers must contact HSD or its designee for UR instructions and compliance.
ALL of the following
- Crisis triage services reimbursed through an agency-specific cost-based bundled rate relative to the type of services rendered; billing details are in the BH policy and billing manual.
Day treatment coverage criteria
Day treatment services (DTS) — coverage, settings, and requirements (EPSDT for <21)
ALL of the following
- MAD pays for DTS as part of EPSDT for eligible recipients under 21; need must be identified via EPSDT tot-to-teen health check or other diagnostic evaluation.
ALL of the following
- DTS must be provided in a school or community setting with distinct separation from other BH services; based on individualized treatment plan; include family engagement and coordination with schools; minimum of four hours structured programming per day, two to five days per week; 24-hour availability of appropriate staff or an implemented crisis plan.
ALL of the following
- Non-covered: formal educational programs, pre-vocational/vocational training related to employment, services not in treatment plan, recreational/leisure activities unrelated to treatment, therapist travel reimbursement, and concurrent partial hospitalization/residential programs.
ALL of the following
- Day treatment does not require prior authorization per general behavioral health rules; services are included in a bundled day treatment rate and claims submitted on CMS-1500 (or successor).
ALL of the following
- Advance schedules for structured activities must be posted and programming include individual, group and family therapy appropriate to age and treatment plan objectives; certified DTS provider responsible for adequate care and continuous supervision during participation.
Family support services coverage criteria
Family Support Services (MCO reimbursed only) — provider qualifications, population, activities, documentation, and reimbursement
ALL of the following
- Providers and staff must meet state standards and BH policy/billing manual requirements; peer/family support staff must maintain New Mexico credentials; clinical supervisor must be a licensed independent practitioner with four years' relevant experience, one year supervisory experience, and completion of basic and supervisory family support training.
ALL of the following
- Members with parents/family/caregivers engaged in the plan of care, young persons with severe emotional disturbance, and adults with serious mental illness per state definitions are eligible populations for family support services.
ALL of the following
- Face-to-face family-based activities to review social history and treatment plans, identify strengths/barriers, participate in planning, provide psychoeducation, problem solving, skills building, navigation of systems, crisis support, and activities to prevent restrictive placement or aid reintegration; tailored to individual needs and linked to treatment plan goals.
ALL of the following
- Notes must document how each activity promoted family support relative to recovery/resilience goals and include any supporting collateral documentation.
ALL of the following
- Centennial Care MCOs reimburse family support services as an MCO-covered benefit; services billable only during specified transition phases from listed residential/inpatient settings per policy; providers receive billing instructions upon enrollment.
Inpatient psychiatric coverage criteria
Inpatient psychiatric care in freestanding psychiatric hospitals and psychiatric units of acute care hospitals — eligible providers, covered components, exclusions, prior authorization, and reimbursement
ALL of the following
- Freestanding psychiatric hospitals and psychiatric units must be licensed/certified by NM DOH (or comparable out-of-state agency), comply with federal regulations (42 CFR 456.201-456.245), and be accredited by JC, COA, CARF or other MAD-recognized accreditor; must be approved MAD providers before furnishing services.
ALL of the following
- MAD covers medically necessary inpatient psychiatric services furnished within provider scope under physician direction; for recipients under 21, services must be under direction of board-prepared/eligible/certified psychiatrist or licensed psychologist collaborating with a psychiatrist, and psychiatrist must evaluate in-person within 24 hours of admission.
ALL of the following
- Providers must perform necessary evaluations/psychological testing, maintain treatment plan and documentation, schedule therapy (individual/group/family), provide age-appropriate skills development, assist with medication self-administration, maintain 24-hour crisis-capable staff, provide consultations, non-medical transportation and discharge planning beginning at admission; treatment plan developed within 72 hours and reviewed at least every five calendar days for freestanding hospitals.
ALL of the following
- Freestanding psychiatric hospitals with more than 16 beds are IMDs; federal IMD exclusion generally prohibits Medicaid payment for recipients aged 22 through 64 (exceptions for under 21 and over 64 apply); managed care IMD in-lieu payments may be limited to 15 days; services may continue for recipients who turn 21 until criteria for continuation are no longer met or until age 22.
ALL of the following
- MAD does not cover conditions defined only by Z codes, services for recipients 22-64 in freestanding psychiatric hospitals subject to IMD rules, services after MAD determines hospital care is no longer needed, formal educational/vocational services except limited non-formal education for under-21 when part of active treatment, and drugs classified as 'ineffective' by FDA.
ALL of the following
- All inpatient services for recipients under 21 in freestanding psychiatric hospitals require prior authorization from MAD or its designee; all MAD services are subject to utilization review which can occur before, during, or after payment; providers may request re-review of denials.
ALL of the following
- Freestanding psychiatric hospitals submit claims on UB-04; reimbursement based on TEFRA cost-settlement principles or provider cost-to-charge ratios where applicable; awaiting placement days for under-21 reimbursed at average accredited residential treatment center rate plus 5%; psychiatrist/psychologist professional services have separate billing rules; MCO contracting provisions apply when billed to coordinated services contractors.
Coverage and criteria for IMD, IOP, and MAT
Coverage criteria, eligible recipients, covered and non-covered services, and reimbursement rules for IMD, IOP (SUD and mental health), and MAT.
ALL of the following
- IMD defined as any facility with more than 16 beds primarily engaged in psychiatric care or treating SUD and not part of a certified general acute care hospital. Based on SPA/1115 waiver, MAD covers inpatient hospitalization in an IMD for SUD when medical necessity is met using SAMHSA admission criteria; coverage may include co-occurring behavioral health disorders when primary diagnosis is SUD; prior authorization required.
ALL of the following
- IOP for SUD eligible for adolescents, transitional age, and adults meeting ASAM level 2.1 or judicial mandate; requires diagnostic evaluation and individualized treatment plan, and is not covered for detained/incarcerated individuals; core services are bundled and MAT/other therapies billed separately.
ALL of the following
- IOP for mental health covers youth 11-17 with SED and adults 18+ with SMI; requires diagnostic evaluation and individualized service plan; core services include individual therapy, group therapy (max 15 members), and psychoeducation; medication management available in-agency or by referral.
ALL of the following
- MAD does not cover acute inpatient, residential treatment, ACT, partial hospitalization, certain outpatient therapies, MST, activity therapy, or PSR group services when billed concurrently with IOP.
ALL of the following
- Prior to starting MAT, assessment and diagnosis by prescribing practitioner for opioid use disorder and readiness for change are required; assessment for concurrent medical/behavioral conditions and co-occurring substance use disorders; education on treatment options; and a service plan prescribing counseling or referral are required. Eligible recipients defined by DSM-5 or ICD-10 opioid use disorder diagnosis.
ALL of the following
- IOP claims submitted on CMS-1500; core IOP services reimbursed via bundled rate; MAT and other therapies billed separately; services not meeting coverage conditions are subject to recoupment; IMD and freestanding psychiatric hospital reimbursement follow TEFRA/cost-settlement or cost-to-charge rules.
Opioid treatment coverage criteria
Eligibility and coverage criteria for opioid-related services and OTPs
ALL of the following
- Assessment and diagnosis by prescribing practitioner for opioid use disorder and readiness for change required prior to treatment; assessment for concurrent medical/behavioral illnesses and co-occurring substance use disorders; education on treatment options and a service plan prescribing counseling or referral required prior to starting treatment.
ALL of the following
- Individuals with an opioid use disorder diagnosis defined by DSM-5 or ICD-10 are eligible for OTP/MAT services.
ALL of the following
- OTP admission requires physician documentation of diagnostic criteria and initial medical exam; maintenance treatment generally requires a 12-month addiction history for maintenance unless specific waivers apply (e.g., recent release from penal institution, pregnancy, recent prior treatment, under-18 with documented attempts and consent).
ALL of the following
- Covered services include withdrawal treatment, medically supervised dose reduction, biopsychosocial assessment within 14 days, individualized treatment plan within 30 days, ongoing medical/psychosocial/vocational services as identified, recordkeeping and diversion controls, monthly random urine drug testing for maintenance, and other toxicology per orders.
ALL of the following
- Blood samples sent to outside laboratories are non-covered; bundled reimbursement includes methadone administration/dispensing and on-site urine dipstick testing; other services (non-methadone drugs, counseling, initial medical exam, confirmatory labs) reimbursed separately per MAD fee schedule.
MST coverage and service requirements
MST eligibility, provider, staffing, service content, and limits
ALL of the following
- Eligible recipients are ages 10-18 who are at risk of out-of-home placement or returning from it, have SED or juvenile justice involvement, antisocial/aggressive/violent/substance-abusing behaviors, or other criteria specified; co-occurring substance use does not exclude eligibility.
ALL of the following
- Agency must hold MST Inc licensure or approved subsidiary licensure; MST team assigned for each recipient with specified staffing mix (minimum two-thirds licensed master's-level staff), weekly supervision and required MST-specific training and supervision protocols; clinical supervision includes weekly individual and group supervision and telephone consultation with MST systems supervisor.
ALL of the following
- Staffing comprised of no more than one-third bachelor's-level staff and at least two-thirds licensed master's-level staff; clinical supervision weekly and mandatory trainings (five-day MST intro and quarterly trainings).
ALL of the following
- Covered MST services include initial assessment, therapeutic interventions with the recipient and family, case management, crisis stabilization, and delivery in home/school/community settings; typical duration 3-6 months with weekly interventions ranging from 3 to 20 hours per week and decreasing toward discharge.
ALL of the following
- MST agencies submit claims on CMS-1500; reimbursement and enrollment follow MAD general rules and BH policy/billing manual guidance; non-covered items subject to general MAD restrictions.
RTC/Group Home coverage and reimbursement
RTC and group home coverage, provider requirements, covered and non-covered services, treatment plan and reimbursement
ALL of the following
- Eligible recipients are under 21 and require determination that RTC/group home level of care is needed after considering least restrictive environments; services provided as part of EPSDT and identified via tot-to-teen health check or diagnostic evaluation.
ALL of the following
- RTC must be certified by CYFD; group homes must be certified/licensed by CYFD; IHS/tribal-operated facilities may use CYFD findings in lieu of licensure and MAD will work with the facility on findings/recommendations.
ALL of the following
- Covered services include assessments, counseling/therapy, age-appropriate skills development, assistance with medication self-administration, 24-hour staff and interdisciplinary treatment program, non-medical transportation, therapeutic services, discharge planning beginning at admission, and access to medical services on a 24-hour basis; staffing ratios appropriate to level of care required.
ALL of the following
- Non-covered: CCSS except for discharge planning, services not medically necessary, room and board, services without prior approval, and services after UR determination that recipient no longer meets LOC, and other general MAD non-covered restrictions.
ALL of the following
- Prior authorization required before RTC/group home services furnished (from MAD, UR contractor, or MCO); claims submitted on UB-04 (or successor); MAD fee schedule established from agency cost data with vacancy factor of 24 days/year built into rate; certain professional services (psychiatrist/PhD psychologist) billed separately.
ALL of the following
- If recipient solely receives RTC/group home services a service plan may not be required; if receiving other BH services a service plan is required; discharge planning must begin at admission with regular assessments to support transition.
OTP coverage, provider and reimbursement criteria
OTP provider requirements, staffing, operational policies, covered services and reimbursement details
ALL of the following
- OTP programs must maintain SAMHSA/CSAT-recognized certification and BHSD approval and must notify BHSD of accreditation issues; program sponsor agreement and adherence to federal/state regulations required.
ALL of the following
- OTP staffing must include a medical director (NM MD/DO), clinical supervisor (licensed psychologist/LISW/CNP/LPCC/LMFT), licensed behavioral health practitioners, RN/LPN, and pharmacist; optional staff include LSAA, CPSW, EMTs with SUD training documentation.
ALL of the following
- Programs must be open daily (with limited holiday/Sunday exceptions), maintain written policies/procedures per BH policy/billing manual, accept transfers, maintain counselor/patient caseload standards, preparedness planning, recordkeeping, diversion control plans, and PMP checks; HIV/AIDS and hepatitis testing/education available or by referral.
ALL of the following
- Covered OTP services include withdrawal treatment, medically supervised dose reduction, biopsychosocial assessment within 14 days, individualized treatment plan within 30 days, medical/psychosocial/vocational services available directly or via formal referral agreements, monthly random urine drug testing for maintenance, and other toxicology per medical orders.
ALL of the following
- Bundled OTP reimbursement covers methadone, administration/dispensing, and on-site urine dipstick testing; other services (non-methadone drugs, counseling beyond federally required, initial medical exam, confirmatory lab tests sent out) are reimbursed separately per MAD fee schedule; blood samples sent to outside labs are non-covered when specified.
Coverage criteria for services in this segment
Coverage and limitations for listed specialized behavioral health services as reimbursed by MAD.
ALL of the following
- Withdrawal treatment, supervised dose reduction, biopsychosocial assessment within 14 days, individualized treatment plan within 30 days, monthly random urine drug testing for maintenance; bundled rate includes methadone administration/dispensing and on-site urine dipstick testing; outsourced confirmatory labs billed separately; blood samples to outside labs noted as non-covered in some contexts.
ALL of the following
- PHP is voluntary, intensive, medically staffed and psychiatrically supervised with interdisciplinary team; H&P within 24 hours, interdisciplinary biopsychosocial assessment within 7 days, individualized treatment plan within 7 days, plan review every 15 days, daily outcome-focused documentation required; staffing includes RN and clinical supervisor and services ordered by psychiatrist or licensed PhD; per diem billing unit represents an 8-hour day; prior authorization required if stay exceeds 45 days; specific non-covered items include meals, provider transportation, primarily recreational activities, and formal academic/vocational services not part of active treatment.
ALL of the following
- PSR covered for adults 18+ with SMI when medically necessary and tied to treatment plan goals; facility-based clubhouse or structured classroom model; core components include basic living skills, psychosocial skills training, therapeutic socialization and individual empowerment; not payable for residents of institutions for mental illness; no prior authorization required though medical necessity may be reviewed retrospectively.
ALL of the following
- Recovery services include peer-to-peer support and related activities delivered individually or in groups; staffed by certified peer support workers and family specialists; these recovery services may not be billed concurrently with MST, ACT, PHP, TLS, or TFC.
ALL of the following
- SBIRT provides universal screening in medical settings with warm hand-off to trained providers; screening with negative results covered for screening only; positive screens for substance use co-occurring with depression/anxiety/trauma are eligible for screening plus brief intervention and referral; screening does not require a diagnosis and brief interventions can be billed with a provisional diagnosis per BH policy/billing manual.
Coverage criteria for SBIRT, PSH-TSS, and TFC
Coverage, eligible populations, covered services, limitations, and duration for SBIRT, PSH-TSS, and TFC are specified below.
ALL of the following
- SBIRT screening with negative results is covered only for the screening component; positive screens for alcohol/other drugs co-occurring with depression, anxiety or trauma are eligible for screening and brief intervention plus referral as needed; screening does not require a diagnosis and brief interventions may be billed with a provisional diagnosis per BH policy/billing manual.
ALL of the following
- PSH-TSS requires enrollment in the Linkages permanent supportive housing program and an assessment documenting serious mental illness; covered pre-tenancy services include screening preferences/barriers, housing support plan and crisis plan, tenancy orientation and move-in assistance, and landlord relationship building; tenancy support services include early identification of issues, coaching, education on tenant responsibilities, advocacy, plan updates and linkages; providers include Linkages program clinics/agencies with licensed behavioral health professionals and certified peer/family support workers; benefit lasts for duration of enrollment in Linkages program and excludes rent/subsidized housing.
ALL of the following
- TFC I for recipients at risk for or returning from higher level care with complex needs; TFC II for those who completed TFC I or require continuity of treatment/support; eligible agencies must be CYFD certified and licensed as child placement agencies or hold equivalent out-of-state accreditation; covered services center on therapeutic family living experiences with treatment planning timelines (initial plan within 72 hours, comprehensive within 14 days), treatment team reviews every 30 days, 24/7 crisis intervention, specified face-to-face and phone contact frequencies for coordinators and parents; non-covered include room and board, formal education/vocational services, respite, and most CCSS except discharge planning; prior authorization required before any TFC service is furnished.
ALL of the following
- PSH-TSS benefit is available for the duration of member's enrollment in Linkages and ceases when client leaves the program; TFC services require prior authorization and remain subject to utilization review.
Billing, coding, and claims guidance
Billing formmixed
| UB-04 | Claim form required for AARTC agencies to submit reimbursement claims. |
Billing forms and fee schedulemixed
| No codes listed |
Billing forms and bundlingmixed
| No codes listed |
ICD-10 exclusion examplesICD-10Not Covered
| Z-codes | Conditions defined only by Z codes are not covered for freestanding psychiatric hospital services. |
Diagnostic coding referencesmixed
| DSM-5 / ICD-10 | Diagnostic criteria required for opioid use disorder and co-occurring diagnoses |
Claim forms and billingmixed
| CMS-1500 or UB-04 | Claim forms required: MST agencies use CMS-1500; RTC/group home use UB-04; OTP reimbursement uses MAD fee schedule and designated claim form. |
Claim forms and payment schedulesmixed
| UB form | Partial hospitalization facility claims to be submitted on UB claim form or successor. |
| CMS-1500 | PSR claims to be submitted on CMS-1500 claim form or successor. |
| MAD fee schedule | Bundled and non-bundled reimbursement references to MAD fee schedules; FQHC/IHS exceptions noted. |
billing guidance referencemixed
| No codes listed |
Typical length of stay for withdrawal management — quick reference (ASAM 3.2WM, 3.7WM)
ASAM 3.2WM typical LOSTypically 3–5 days (recipient remains until withdrawal signs/symptoms sufficiently resolved or transfer is indicated)
ASAM 3.7WM typical LOSUp to 7 days for medically monitored residential withdrawal management (3.7WM)
Treatment plan review cadenceInterdisciplinary team reviews treatment plan every 15 days for withdrawal management programs
Supervision/clinical management threshold — when to document additional supervision time
Supervision hours documentation thresholdDocument number of supervision hours when more than 2 hours of supervision are requested per 10 hours of intervention
Clinical management documentation thresholdDocument clinical management hours when more than 2 hours of clinical management are requested per 10 hours of intervention
Prior authorization contextThese supervision/clinical management hours must be included in stage three prior authorization requests every six months
CET bundled vs separate billing — which CET services are bundled and which bill separately
CET core services billingCore CET services are reimbursed through a bundled rate (agency-level bundled payment)
CET medications and other therapiesMedications and other mental health therapies are billed and reimbursed separately from the CET bundled rate
CET provider billingCET services furnished by a CET team member are billed by and reimbursed to the MAD CET agency regardless of employment/contract status
Claim form requirement — CMS-1500 or successor requirement
Claim form requirement (general)Claims must be submitted on CMS-1500 or its successor for applicable professional services
IOP and CET claim formsIOP and CET agencies submit claims on CMS-1500 or successor as specified in program sections
Facility claims referenceSome facility services (e.g., PHP partial hospitalization facility claims) use UB-04 or successor per program rules
IMD bed count threshold — IMD age exclusion note for freestanding psychiatric hospitals >16 beds
Freestanding psychiatric hospitals >16 beds — IMD age exclusionFreestanding psychiatric hospitals with more than 16 beds are considered IMDs and subject to the federal IMD exclusion for ages 22–64 (with exceptions for under 21 and over 64 and certain SUD IMD coverage under SPA/1115)
Continuation when turning 21If a recipient receiving inpatient services turns 21, services may continue until they no longer require services or reach age 22, whichever occurs first
IMD SUD exceptionIMD inpatient hospitalization for SUD may be covered under state plan amendment/1115 waiver using ASAM medical necessity criteria
IMD bed threshold — numeric threshold for IMD definition
Numeric IMD bed threshold>16 beds (facility primarily engaged in psychiatric care or treating SUD not part of a general acute care hospital)
Federal IMD exclusion age bandMedicaid IMD exclusion generally prohibits payment for recipients aged 22–64 for IMDs
Coverage exceptionsCoverage for SUD IMD stays may be allowed per SPA/1115 waiver with ASAM medical necessity criteria; under-21 and over-64 not subject to age exclusion
IOP group size maximum — group therapy size limit
IOP group therapy maximumGroup membership may not exceed 15 members
IOP core componentsIOP core services include individual therapy, group therapy (<=15), and psychoeducation; medication management available in-agency or by referral
Typical IOP durationIOP intervention typically lasts 3–6 months
OTP urine drug testing frequency — random UDT frequency for maintenance patients
OTP random UDT frequency (maintenance)Maintenance patients receive one random urine drug detection test per month
Short-term withdrawal UDTShort-term opioid withdrawal procedure patients receive at least one initial drug abuse test
Long-term withdrawal UDTLong-term opioid treatment withdrawal procedure patients receive an initial and monthly random tests
PHP billing unit — per diem = 8 hours and billable fractions
PHP billing unit definitionPer diem represents 8 hours of service (per diem = 8 hours)
Billable fractional unitsBillable fractions of .25, .5, or .75 units represent 2, 4, or 6 hours respectively
Professional services billingProfessional services (physician/PhD psychologist) are billed separately from the per diem rate
TFC treatment plan deadlines — initial and comprehensive plan timeframes
TFC initial treatment plan deadlineInitial treatment plan must be developed within 72 hours of admission
TFC comprehensive plan deadlineComprehensive treatment plan must be developed within 14 calendar days of admission
Treatment team review frequencyTreatment team must review the treatment plan every 30 calendar days
Prior authorization, utilization review, and provider obligations
Prior Authorization
Prior authorization and utilization review rules
Prior authorization is not required for up to five days for eligible recipients meeting ASAM level three criteria to facilitate immediate admission and treatment; if continued care beyond the initial five days is medically necessary the provider must obtain prior authorization from MAD or its designee. All MAD services remain subject to utilization review for medical necessity, inspection of care, and program compliance; services with prior authorization remain subject to UR throughout the payment process.
- For out-of-state AARTCs, prior authorization is required prior to admission.
- Providers must notify MAD of admissions within the five-day waiver period and obtain PA if continued stay is needed.
Documentation Required
Follow HSD utilization review procedures
Providers must contact HSD or its authorized agents to request utilization review (UR) instructions and follow UR procedures; URs may be performed pre-service, pre-payment, or post-payment. It is the provider's responsibility to obtain, understand, and comply with UR instructions and to follow any coordinated services contractor's authorization processes when applicable.
- UR may occur before services are furnished, after services but before payment, or after payment.
- Providers must keep documentation available for HSD or designee review.
Prior Authorization
WM prior authorization waiver (up to 5 days)
For withdrawal management (WM) at ASAM level three, prior authorization is waived for up to five days to allow immediate admission; if the provider believes continued care beyond five days is medically necessary they must obtain prior authorization from MAD or its designee.
- During the initial five-day period the provider must furnish notification of the admission.
- Services for which prior authorization is obtained remain subject to utilization review.
Prior Authorization
Obtain prior authorization for ARTC services
Before furnishing any Adult Accredited Residential Treatment Center (ARTC) services to an eligible recipient, the provider must obtain prior authorization from MAD or its designee. Services authorized remain subject to utilization review at any point in the payment process.
- ARTC agencies submit claims on UB-04 and follow MAD billing instructions after enrollment.
- The MAD fee schedule and routine service definitions apply to ARTC reimbursement.
Prior Authorization
ABA stage three prior authorization every 6 months
Most ABA stage three services require prior authorization which must be secured every six months; authorization requests must include the CDE/ISP, ABA treatment plan, requested treatment model and hours, and documentation of supervision and clinical management hours when thresholds are exceeded.
- Prior authorization requests must document other ISP services and hours to allow UR to assess the requested intensity.
- Families or AP may request ISP modifications before the six-month review if warranted to preserve health and wellbeing.
Prior Authorization
Acceptable prescribers for stage three PA
Acceptable prescribers for stage three prior authorization requirements include a board certified or board eligible psychiatrist, a New Mexico licensed psychiatric-certified nurse practitioner, a New Mexico licensed psychiatric clinical nurse specialist, or a prescribing psychologist under MD supervision/consultation.
- Prior authorization documentation must identify the acceptable prescriber as required.
Prior Authorization
HSD ACT approval letter and variance requirement
ACT agencies must possess an HSD ACT approval letter to render ACT services; any adaptations to the ACT model require an approved variance from BHSD before implementation.
- The approval letter authorizes agencies delivering CSC services to also deliver ACT when specified.
- Agencies must adhere to ACT model composition and fidelity requirements unless a variance is approved.
Prior Authorization
Respite >30 days/720 hours requires PA
Behavioral health respite exceeding 30 days or 720 hours in a year requires prior authorization; respite services beyond that threshold may not be billed with certain concurrent residential or institutional services and do not cover room and board.
- BH respite may be provided for a few hours up to overnight stays, but once 30 days/720 hours per year is reached PA is required.
- BH respite may not be billed in conjunction with treatment foster care, group home, residential services, or inpatient treatment.
Note
Crisis triage PA exemption; follow UR for other services
Crisis triage services do not require prior authorization, but providers must contact HSD or its designee for UR instructions and comply with utilization review requirements; other services provided during crisis care (for example inpatient admission) may require prior authorization.
- UR may be performed at any time during service delivery, payment, or post-payment.
- Providers agree to cooperate fully with MAD or its designee in UR by signing the MAD PPA.
Prior Authorization
PA required for inpatient services <21 in freestanding psychiatric hospitals
All inpatient services for recipients under 21 in a freestanding psychiatric hospital require prior authorization from MAD or its designee; providers may request re-review or reconsideration for denials.
- Providers must verify the recipient's MAD eligibility at time services are furnished and during the inpatient stay.
- Services authorized remain subject to utilization review at any point in the payment process.
Documentation Required
All MAD services subject to utilization review
All MAD services are subject to utilization review for medical necessity, inspection of care, and program compliance; providers must follow UR instructions from HSD or its designee and understand that prior authorization does not guarantee eligibility or payment.
- UR can occur before, during, or after payment is made.
- When billing a coordinated services contractor, providers must follow that contractor's authorization instructions.
Prior Authorization
PA required for IMD stays (use SAMHSA criteria)
Prior authorization is required for IMD stays for substance use disorder; providers must use SAMHSA admission criteria to establish medical necessity for IMD admission.
- IMD is defined as any facility with more than 16 beds primarily engaged in psychiatric or SUD care; federal IMD exclusion applies to ages 22-64 except as covered under SPA/1115 waiver.
- Reimbursement for IMD stays follows specified inpatient provisions.
Prior Authorization
Obtain PA before RTC or group home services
Prior authorization is required from MAD, its utilization review contractor, or the Centennial Care MCO before RTC or group home services are furnished; services for which prior authorization was obtained remain subject to utilization review.
- RTC/group home claims are submitted on UB-04 and follow MAD fee schedule rules.
- Services furnished without prior authorization or after a determination that LOC is no longer met are non-reimbursable.
Prior Authorization
PA required for PHP stays >45 days (continued stay authorization)
Partial hospitalization (PHP) does not require prior authorization for admission unless the length of stay exceeds 45 days; if stay exceeds 45 days the provider must request authorization for continued stay documenting the need, response to therapy, ongoing risk of hospitalization, and expectations for improvement.
- The authorization request must explain why a lower level of outpatient services is not advised and include treatment goals for discharge planning.
- PHP claims are submitted on the UB claim form or successor and per-diem represents an eight-hour day.
Prior Authorization
PSR does not require PA; retrospective medical necessity review may apply
No prior authorization is required for Psychosocial Rehabilitation (PSR); however, medical necessity may be determined retrospectively using recipient assessment, diagnosis, and treatment plans.
- PSR claims are submitted on CMS-1500 or successor.
- PSR cannot be billed concurrently when the recipient is a resident of an institution for the mentally ill.
Prior Authorization
Obtain PA before providing TFC services
Before any Treatment Foster Care (TFC) service (TFC I or II) is furnished to an eligible recipient, prior authorization is required from MAD or its utilization review contractor; services authorized remain subject to utilization review.
- TFC agencies must be CYFD certified and licensed as a child placement agency or hold equivalent out-of-state accreditation/licensure.
- TFC treatment plans: initial within 72 hours and comprehensive within 14 calendar days; 24/7 crisis intervention required.
Key definitions and program descriptions
PPA — Provider participation agreement definition
DefinitionProvider participation agreement (PPA): Agreement a provider must have with New Mexico MAD to be eligible for reimbursement for furnishing MAD covered services; provider must be approved before submitting claims
Payment methodMAD issues payment to providers via electronic funds transfer (EFT) only as specified in the PPA
Provider responsibilitiesProviders must adhere to provisions of the PPA and comply with applicable statutes, rules, program manuals, and billing instructions
ASAM level three — ASAM 3.* definitions and withdrawal management sublevels
ASAM level three scopeASAM level three includes residential levels such as 3.1 (clinically managed low-intensity), 3.2WM (clinically managed withdrawal management), 3.3 and 3.5 (clinically managed high-intensity), and 3.7 (medically monitored intensive inpatient)
3.2WM characteristicsClinically managed residential withdrawal management overseen by behavioral health professionals with protocols for medical escalation; typically 3–5 day length of stay
3.7 / 3.7WM characteristicsMedically monitored services delivered by medical and nursing professionals with 24-hour nursing on-site and physician/NP availability; 3.7WM provides medically monitored withdrawal management (up to 7 days)
BA / BAA / BT — Behavior Analyst / Assistant definitions
BA (Behavior Analyst)Board certified behavior analyst (BCBA®/BCBA‑D®) or psychologist certified in behavior/cognitive psychology who may render ABA stage two assessments and stage three services
BAA (Behavior Analyst Assistant)Board certified assistant behavior analyst (BCaBA®) who may assist the supervising BA with stage two and stage three services as delegated
BT (Behavior Technician)Behavior Technician who, under supervision of a BA, may assist in stage two and implement stage three ABA treatment plan interventions
AEP — Autism Evaluation Provider definition and role
AEP roleAutism Evaluation Provider (AEP) completes a comprehensive diagnostic evaluation (CDE), determines presence/risk of ASD, and develops the integrated service plan (ISP) for stage one
AEP outputAEP issues the CDE, targeted evaluation, or risk evaluation and provides referral to approved ABA provider for subsequent stages
AEP requirementConfirmation of ASD must occur through an approved AEP using a comprehensive diagnostic evaluation
Assertive outreach — definition and limit of outreach time per member
Assertive outreach definitionACT team assertive outreach is locating the individual or acting quickly and decisively on the individual's behalf and may only comprise 5% of the individual's total service time per month
PurposeAssertive outreach aims to increase client independence while addressing immediate needs such as engagement and crisis response
Billing/coverage contextAssertive outreach is part of medically necessary ACT services covered under the ACT program rules
ACT identified population — adults 18+ with SMI and first-episode psychosis age band
ACT primary adult populationAdults 18 and older with serious mental illness (e.g., schizophrenia, schizoaffective, bipolar, psychotic depression) who have severe ADL impairments or repeated hospitalizations/incarcerations
First-episode psychosis bandAlso eligible: individuals 15–30 years old within the first two years of first-episode psychosis
Co-occurring SUDA co-occurring substance use diagnosis does not exclude eligibility for ACT services
CET — Cognitive Enhancement Therapy program definition and BHSD approval requirement
CET definitionCognitive Enhancement Therapy (CET) is an evidence-based program for adults 18+ with cognitive impairment associated with certain serious mental illnesses and requires BHSD approval and fidelity to the model
CET intensityPer-model fidelity each participant may receive up to 3 hours group plus up to 1 hour individual coaching per week
CET billingCore CET services are bundled; medications and other therapies billed separately; providers must submit claims on CMS-1500 or successor
On-site administrator / clinical director — crisis triage staffing definition
On-site administrator/clinical director requirementCrisis triage centers must have an on-site administrator (or same person as clinical director) experienced in acute mental health and a full-time clinical director who is a licensed independent mental health practitioner or CNP/CNS with acute mental health/WM experience
Minimum qualificationsAdministrator at least 21 years old with bachelor’s degree or RN; clinical director at least 21 and licensed with relevant experience; charge nurse on duty at all hours
24/7 staffing expectationCenters must staff certified peer support workers appropriate to meet client needs 24/7 and have on-call physician coverage during all hours of operation
CPSW — Certified peer support worker certification and 24/7 staffing expectation
CPSW certification requirementCertified peer support workers (CPSW) must hold New Mexico certification through the credentialing board for behavioral health professionals
Staffing expectationCPSWs must be staffed appropriate to meet client needs 24 hours a day, 7 days a week
Role contextCPSWs provide recovery support activities and may participate in SBIRT and other community-based interventions as trained
IMD — IMD definition in context of freestanding psychiatric hospitals >16 beds
IMD definition for freestanding psychiatric hospitals >16 bedsA freestanding psychiatric hospital with more than 16 beds is an Institution for Mental Disease (IMD) and is subject to the federal IMD exclusion for recipients aged 22–64 (with exceptions for under 21 and over 64)
Coverage nuanceManaged care organizations may pay for short IMD in-lieu stays (e.g., <=15 days) and SUD IMD stays may be covered under SPA/1115 with ASAM criteria
Continued care when turning 21If recipient reaches 21 while in IMD, services may continue until no longer needed or until the recipient reaches 22
IMD — broader IMD definition for facilities primarily engaged in psychiatric care
Broader IMD definitionAn IMD is any facility with more than 16 beds primarily engaged in psychiatric care or treating SUD that is not part of a certified general acute care hospital
Federal age restrictionFederal IMD exclusion generally prohibits Medicaid payment for ages 22–64, with state plan/waiver exceptions for SUD and other conditions per medical necessity
Prior authorizationPrior authorization is required for IMD stays and SAMHSA admission criteria should be used for medical necessity determinations
MAT (buprenorphine) — MAT definition excluding methadone contexts
MAT (buprenorphine) definitionMedication Assisted Treatment (MAT) for opioid use disorder includes administration of opioid replacement medication excluding methadone per DATA 2000, CARA, and SUPPORT Act
Pre-treatment requirementsAssessment and diagnosis by prescribing practitioner, assessment for co-occurring conditions, education on options, and a service plan with counseling or referral required prior to treatment
Eligible diagnosisRecipients must meet DSM-5/ICD-10 criteria for opioid use disorder to be eligible for MAT
MST — Multisystemic Therapy definition reference
MST definitionMultisystemic Therapy (MST) is an intensive home, family and community-based treatment for youth ages ~10–18 at risk of out-of-home placement or returning from it
Provider requirementAgencies must hold MST Inc licensure (or approved subsidiary) and implement MST team-based services
Typical duration and intensityTypical MST duration 3–6 months with 3–20 hours/week of therapist contact depending on need
OTP — Opioid Treatment Program definition and regulatory references
OTP definition and regulatory referencesOpioid Treatment Program (OTP) provides medication-assisted treatment including methadone in accordance with 42 CFR Part 8 and state BHSD accreditation/approval requirements
Program componentsIncludes withdrawal treatment, biopsychosocial assessment within 14 days, individualized treatment plan within 30 days, counseling, case review, and drug testing
Reimbursement noteBundled OTP rate covers methadone, administration/dispensing, and on-site urine dipstick testing; outsourced confirmatory labs billed separately
Partial Hospitalization Program (PHP) — PHP definition and team requirements
PHP definitionPartial Hospitalization Program (PHP) is a voluntary, intensive, structured, medically staffed program with an interdisciplinary team for stabilization of acute psychiatric or SUD symptoms, less than 24 hours/day and time-limited
Team requirementsPHP requires an interdisciplinary team including psychiatrist oversight, RN, clinical supervisor, and licensed behavioral health practitioners; H&P within 24 hours and biopsychosocial assessment within 7 days
Billing unitPer diem represents 8 hours; fractions billed as .25/.5/.75 units for 2/4/6 hours respectively
Psychosocial Rehabilitation (PSR) — PSR definition and target population
PSR definitionPsychosocial Rehabilitation (PSR) is an array of group-based clubhouse or classroom services for adults 18+ with SMI to develop coping strategies, life skills, and community functioning as a transitional level of care
Target populationAdults 18 years and older who meet criteria for serious mental illness (SMI)
Service examplesIncludes basic living skills, psychosocial skills training, therapeutic socialization, and individual empowerment tied to treatment plans
SBIRT — Screening, Brief Intervention & Referral to Treatment definition
SBIRT definitionScreening, Brief Intervention & Referral to Treatment (SBIRT) is a community-based practice for universal screening in medical settings, brief intervention for positives, and warm hand-off/referral to behavioral health
Provider/practitioner scopeProviders include primary care, FQHCs, urgent care, EDs, clinics and trained practitioners (nurses, physicians, behavioral health practitioners, CPSWs, CHWs, etc.)
Coverage limitationScreening with negative results is eligible only for the screening component; positive screens with co-occurring depression/anxiety/trauma eligible for brief intervention and referral
PSH-TSS — Permanent Supportive Housing Pre-Tenancy and Tenancy Support Services definition
PSH-TSS definitionPermanent Supportive Housing Pre-Tenancy and Tenancy Support Services (PSH-TSS) are MCO-only services to facilitate community integration, including pre-tenancy support, tenancy orientation, landlord relationship services, coaching and linkages for eligible recipients enrolled in Linkages program
Eligible providersAny clinic, office or agency providing permanent supportive housing under HSD Linkages program; behavioral health practitioners and certified peer/family peer support workers
Reimbursement noteFollow BH policy and billing manual and Subsection H of 8.321.9 NMAC; services do not include rent or subsidized housing
Treatment Foster Care (TFC) I and II — TFC levels and target recipients under 21
TFC levels and recipientsTreatment Foster Care (TFC) I and II are EPSDT services for recipients under 21 needing therapeutic family living: TFC I for those at risk for or returning from higher level of care; TFC II for continuation/step-down or those completing TFC I
Initial and comprehensive plan deadlinesInitial treatment plan within 72 hours; comprehensive treatment plan within 14 calendar days of admission
Care requirementsTFC requires intensive support/supervision of foster parents, treatment team reviews every 30 days, and 24/7 crisis intervention
SBIRT coverage limitation — screening-only SBIRT for negative results limitation
SBIRT screening-only coverage limitationSBIRT screening with negative results is eligible only for the screening component (no brief intervention billed for negative screens)
Positive screen coveragePositive screens for alcohol/other drugs co-occurring with depression/anxiety/trauma eligible for screening plus brief intervention and referral to treatment
Coding guidanceScreening does not require a diagnosis; brief interventions may be billed with a provisional diagnosis per BH policy and billing manual
Policy Summary
PayerNew Mexico Health Care Authority
PolicySpecialized behavioral health provider enrollment and reimbursement
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateAug 10, 2021
Last ReviewAug 10, 2021
Next Review DateN/A
Key ActionPrior authorization is not required for up to five days for eligible recipients meeting ASAM level three criteria; obtain prior authorization for continued care beyond five days.
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