Transportation Services and Lodging (MAD)
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Governs coverage, provider eligibility, responsibilities, prior authorization, utilization review, and reimbursement for transportation, lodging, meal, and attendant-related expenses for New Mexico medical assistance program (MAP) eligible recipients.
No material clinical or coverage changes in this revision.
MAD Transportation, Lodging, Meal, and Attendant Coverage
MAD transportation coverage criteria
Covered when ALL of the following MAD conditions are met:
ALL of the following
ALL of the following
- Provider must comply with federal, state, and local laws, the provider participation agreement, MAD NMAC rules, billing instructions, and UR directions; follow coding manual guidelines and CMS correct coding initiatives (no improper unbundling or upcoding).
Providers must verify eligibility, enrollment status, other insurance, and maintain sufficient records.
- Providers must enroll and submit claims on CMS-1500 (or successor) and supply EFT information; follow PPA, NMAC rules, billing instructions, and contact HSD for billing questions.
ALL of the following
- Free alternatives must be used when available (volunteers, relatives, facility-provided transport).
- MAD covers the most appropriate and least costly transportation suitable to the recipient's medical or behavioral health condition; private vehicle or public transport must be used before more expensive options if available.
Types of covered transport (one or more)
- Non-emergency transportation: covered when recipient has no primary transportation and cannot access less costly public transportation (subject to non-covered services rules).
- Long-distance common carrier: covered if recipient must leave home community to receive services; authorization forms available through county ISD for direct payment to carriers.
- Ground ambulance: covered for emergencies certified by a physician or documented as meeting emergency medical necessity; scheduled non-emergency ground ambulance requires PCP order certifying contraindication to other transport. Base rate includes non-reusable items, oxygen, and mileage for first 15 miles.
- Air ambulance: covered when an emergency exists and PCP certifies medical necessity; base rate includes non-reusable items, oxygen, professional attendants, detention/standby time, and equipment use.
ALL of the following
- 'Emergency' means a condition with acute symptoms of sufficient severity that a prudent layperson could reasonably expect absence of immediate attention to result in serious jeopardy, serious impairment, or serious dysfunction.
- 'Medical necessity' for ambulance services exists when the recipient's physical or behavioral health condition contraindicates any other method of transportation and would endanger the recipient's health.
ALL of the following
- Lodging: covered if recipient must travel more than four hours one way and an overnight stay is required due to medical necessity or cost considerations. Initial lodging may be authorized up to 5 continuous days; re-evaluate by day 5 to authorize up to an additional 15 days, and re-evaluate every 15 days for extended stays. Authorization is based on the provider's statement of need; forms available through county ISD.
- Meals: covered when recipient must leave home community for eight hours or more to receive services; authorization forms available through county ISD.
Attendant coverage
- MAD covers transportation, meals, and lodging for one attendant when medical necessity is certified in writing by the medical provider or the recipient receiving services is under 18 years of age. The attendant for a child under 18 should be a parent or legal guardian.
- MAD does not cover transportation services or related expenses of children under 18 years of age traveling with an adult recipient.
ALL of the following
- Transportation to/from a waiver service provider is covered only when the service is physical therapy, occupational therapy, speech therapy, or a behavioral health service.
ALL of the following
- Out-of-state transportation and related expenses require prior authorization by MAD or its designee and are authorized only if the out-of-state service is approved; documentation must justify travel and verify that treatment is not available in New Mexico. Requests must be coordinated through MAD.
- Authorization for lodging and meal services by an out-of-state provider may be granted for up to 30 days with re-evaluation prior to expiration and every 30 days thereafter. Transportation to border cities within 100 miles of the New Mexico border (Mexico excluded) is treated as in-state.
ALL of the following
- MAD does not pay to transport a recipient to a medical or behavioral health service or provider that is not covered under MAD. Providers are not eligible to seek reimbursement from a recipient if they fail to notify the recipient that the service is not covered. Transportation services will not be provided when other alternatives are available (e.g., mail delivery).
ALL of the following
- Reimbursement is the lesser of the provider's billed charge (usual and customary or tariff-limited) or the MAD fee schedule/maximum allowed amount. Air ambulance rates do not include gross receipts tax (provider exempt).
- Ground ambulance base rate includes reimbursement for ALS/BLS equipped service, oxygen, disposable supplies, medications, and mileage for the first 15 miles; scheduled non-emergency base rate likewise includes first 15 miles.
- Non-emergency transportation reimbursed at the lesser of approved tariff or MAD rate; reimbursement limited per one-way trip and MAD does not pay for portions of trips when the recipient is not in the vehicle. 'Additional passenger transport' (two or more recipients picked up at same location to same provider) is not covered except MAD will allow coverage for one recipient in that scenario.
ALL of the following
- Providers must obtain and retain written verification for travel over 65 miles: referring provider verification listing service, out-of-community provider name, and justification that care is unavailable locally; renew every six months for continued non-emergency out-of-community transport.
- All MAD services are subject to utilization review for medical necessity and program compliance; prior authorization does not guarantee eligibility.
ALL of the following
- Providers must enroll as MAD providers and submit claims on CMS-1500 (or successor), following enrollment and claims rules.
ALL of the following
- Reimbursement is limited per one-way trip; MAD does not reimburse for any portion of a trip for which the recipient is not in the vehicle. Additional passenger transports of multiple MAP recipients picked up together are not covered; coverage may be allowed for one recipient.
ALL of the following
- Covered with defined medical necessity and administrative criteria; services must meet MAD documentation, authorization, and reimbursement rules.
Coding and Reimbursement Rules
| Providers must follow coding manual guidelines and CMS correct coding initiatives; avoid unbundling or upcoding. |
Prior Authorization, Documentation, and Referral Requirements
Obtain prior authorization for certain services and out-of-state travel; comply with UR
Certain procedures or services, and out-of-state transportation and related lodging/meals, require prior authorization from MAD or its designee. All MAD services remain subject to utilization review for medical necessity and program compliance; providers must contact HSD or its authorized agents to request UR instructions and follow any coordinated services contractor's authorization instructions. Prior authorization does not guarantee recipient eligibility; providers must verify eligibility and other insurance at time of service.
- Prior authorization required for certain procedures or services from MAD or its designee.
- Lodging and meals for out-of-state travel may be authorized (see coverage limits) but remain subject to re-evaluation and UR.
- Providers must contact HSD or its authorized agents for UR and authorization instructions and follow coordinated services contractor procedures when applicable.
- Prior authorization does not guarantee MAD eligibility; verify eligibility and other insurance at time of service.
Retain written referral verification for travel over 65 miles; renew every six months
For MAP recipients who must travel over 65 miles from their home community, the transportation provider must obtain and retain written verification from the referring provider or service provider that lists the service, the out-of-community provider name, and justification that the care is not available in the home community. For continued non-emergency out-of-community transport, this information must be re-obtained every six months.
- Written verification must include: (a) the medical, behavioral health or diagnostic service being referred; (b) name of the out-of-community provider; and (c) justification that care is not available locally.
- Referrals and referral information must be obtained from a MAD provider.
- For continued non-emergency out-of-community transportation, update the required information every six months.
Key Definitions
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