CurrentNew Mexico Health Care AuthorityPolicy N/A

Clinic Services (including Renal Dialysis Clinics) — Coverage Criteria

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Defines New Mexico Medicaid coverage and limitations for clinic services under Section 1905(a)(9) of the Social Security Act, including specific provisions for renal dialysis clinics and IHS/Tribal clinics. Affects providers furnishing outpatient clinic services to New Mexico Medicaid beneficiaries.

Policy Summary

PayerNew Mexico Health Care Authority

PolicyClinic Services (including Renal Dialysis Clinics) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2025

Next Review DateN/A

Key ActionAttach medical justification to claims for any dialysis training beyond 15 sessions.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

15dialysis training sessions covered without special medical justification

3 monthsinitial renal dialysis coverage when Medicare pending

IHS / TribalIHS / Tribal clinics selected

Selected

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CurrentNew Mexico Health Care AuthorityPolicy N/A

Clinic Services (including Renal Dialysis Clinics) — Coverage Criteria

Customize your policy alerts

Sign up for all New Mexico Health Care Authority policy alerts

Know when New Mexico Health Care Authority releases new policies or updates existing guidance.

Monitor payer policy activity

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Policy Summary

PayerNew Mexico Health Care Authority

PolicyClinic Services (including Renal Dialysis Clinics) — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2025

Next Review DateN/A

Key ActionAttach medical justification to claims for any dialysis training beyond 15 sessions.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

15dialysis training sessions covered without special medical justification

3 monthsinitial renal dialysis coverage when Medicare pending

IHS / TribalIHS / Tribal clinics selected

Selected

Coverage Criteria for Clinic Services

Renal dialysis clinic coverage and limits

Covered when the following conditions are met:

Initial dialysis coverage when Medicare pending: The New Mexico Medicaid Program will cover services for renal dialysis for the first three months of dialysis if not covered by Medicare pending the establishment of Medicare eligibility.3 months

Supports beneficiaries awaiting Medicare eligibility.

Dialysis training sessions: Fifteen sessions of dialysis training are covered without special medical justification; additional sessions require medical justification attached to the claim.15 sessions

Claims exceeding 15 sessions need justification attached to the claim.

Clinic service furnishing requirements and exceptions

Covered when provided in accordance with federal regulation and state assurances:

Facility and supervision requirements: Services must be furnished by a facility that is not part of a hospital, organized to provide medical care to outpatients, and furnished under the direction of a physician in accordance with 42 C.F.R. 440.90.

State certifies these general assurances per 42 C.F.R. 440.90.

Four Walls exceptions: Services may be furnished outside the clinic by clinic personnel under the direction of a physician for specified populations, including individuals without a fixed address and services furnished outside an IHS or Tribal clinic as authorized.

State elected Four Walls exceptions for these circumstances.

Ambulatory Surgical Center (ASC) facility services

ASC facility services are covered when ALL of the following are met:

ASC coverage conditions: 1) The surgical procedure and use of the Ambulatory Surgical Center are medically necessary and are a benefit to the program. 2) All program requirements for the surgery are met by the physician, including valid consent forms and any prior approval requirements.

Operational and documentation requirements must be satisfied for ASC facility coverage.

The state did not select Behavioral Health Clinics in the "Types of Clinics and Services" selection for Section 1905(a)(9) clinic services. This means behavioral health clinics are not included among the clinic types designated as covered under this supplement to the state plan.

Coding and Session Limits

Dialysis training sessions

Dialysis training session limit15 sessions covered without special medical justification; additional sessions require medical justification attached to the claim.

Initial dialysis coverage when Medicare pendingServices covered for the first 3 months of dialysis if not covered by Medicare pending establishment of Medicare eligibility.

Documentation requirement for excess sessionsMedical justification must be attached to the claim when requesting coverage for more than fifteen dialysis training sessions.

Provider Requirements and Documentation

Prior Authorization

ASC facility obligations: consent, physician responsibilities, prior approvals

ASC facility services are covered only when the surgical procedure and use of the facility are medically necessary and a benefit to the program, and the physician meets all program requirements for the surgery such as obtaining valid consent forms and fulfilling prior approval requirements.

Ensure the surgical procedure is medically necessary and benefits the Medicaid program.
Obtain and document valid patient consent forms.
Complete any required prior approval or other program-specific prerequisites before the ASC service.

Note

Provider alert: program conditions and training limits

Providers must follow the program conditions for ASC coverage and the dialysis training limits: verify medical necessity and attach required justification to claims when limits are exceeded.

Confirm procedures meet medical necessity and program benefit tests before billing.

Definitions and Exceptions

Clinic services (definition)

Definition of clinic servicesServices furnished by a facility that is not part of a hospital, organized and operated to provide medical care to outpatients and furnished under the direction of a physician in accordance with 42 C.F.R. 440.90.

State assuranceThe state assures these services are furnished in accordance with 42 C.F.R. 440.90 and under physician or dentist direction per 42 C.F.R. 440.90(a).

Applicable benefit categoryClinic services are covered under Section 1905(a)(9) of the Social Security Act as described in the State Plan attachment.

Four Walls Exceptions (services outside the clinic)

Four Walls exceptions — unhoused individualsServices may be furnished outside the clinic by clinic personnel under physician direction to eligible individuals who do not reside in a permanent dwelling or do not have a fixed home or mailing address (42 C.F.R. 440.90(b)).

Background

Renal dialysis clinics provide outpatient dialysis services and are explicitly selected as a covered clinic type under Section 1905(a)(9). Coverage includes time-limited support for beneficiaries awaiting Medicare eligibility: the program will cover renal dialysis services for the initial 3 months of dialysis while Medicare eligibility is pending.

Dialysis training is addressed with a specific session limit: 15 sessions of dialysis training are covered without special medical justification. Claims requesting more than 15 training sessions must include medical justification attached to the claim. Additionally, ambulatory surgical center (ASC) facility services related to dialysis are covered only when program and physician operational requirements are satisfied (for example, valid consent and any required prior approvals).