Medicaid Managed Care Client Transition of Care
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State rule governing transition-of-care policies, prior authorizations, provider payments, and claims responsibilities for New Mexico Medicaid managed care organizations (MCO), the state enrollment (SE), CoLTS, and HSD; applies to the general public and Medicaid-eligible members moving between coverage types or care settings.
No material clinical or coverage changes in this revision.
Transition of Care Coverage Criteria
Transition of care coverage criteria
Coverage and payment obligations during member transitions, mass transfers, and contract terminations are subject to the following conditions and timeframes.
Provider Responsibilities and Transition Actions
Honor practitioner prior authorizations for 60 days after mass transfer
All practitioner authorizations granted before a mass transfer must be honored for 60 days or until the receiving MCO has made other arrangements; providers who delivered these approved services shall be reimbursed by the receiving MCO. The receiving MCO is also responsible to pay for prescription refills for the first 90 days and for DME delivered after the mass transfer as described in policy.
- Receiving MCO honors practitioner authorizations for 60 days or until other arrangements are made.
- Providers who delivered approved services shall be reimbursed by the receiving MCO.
- Receiving MCO pays prescription refills for the first 90 days or until other arrangements are made.
- Receiving MCO pays for DME delivered after the mass transfer.
Honor prior authorizations for newly enrolled members for 30 days
For newly enrolled members, the MCO and SE shall honor all prior authorizations granted by HSD through its contractors or the CoLTS MCO for the first 30 days of enrollment or until the MCO and SE have made other arrangements for transition of services; providers who delivered services approved by HSD contractors shall be reimbursed by the MCO and SE.
- MCO and SE honor HSD/CoLTS prior authorizations for the first 30 days of enrollment or until other arrangements are made.
- Providers who delivered HSD-approved services shall be reimbursed by the MCO and SE.
Payment for prescription refills during initial 30-day transition
For newly enrolled members, the MCO and SE shall pay for prescription drug refills for the first 30 days of enrollment or until the MCO and SE have made other arrangements; drugs prescribed by a licensed behavioral health provider shall be paid by the SE.
- MCO and SE pay for prescription refills for the first 30 days or until other arrangements are made.
- All drugs prescribed by a licensed behavioral health provider are paid by the SE.
Durable Medical Equipment (DME) and Cost Responsibility
Key Definitions
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