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CurrentNew Mexico Health Care AuthorityPolicy N/A

Agency-Based Community Benefit (ABCB) — Coverage Criteria for Home and Community-Based Services

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Standards, service definitions, provider requirements, and reimbursement rules for Agency-Based Community Benefit services (Home and Community-Based Services) under the New Mexico Medicaid 1115 waiver, affecting Centennial Care MCOs, eligible ABCB providers, and members receiving ABCB services.

Policy Summary

PayerNew Mexico Health Care Authority

PolicyAgency-Based Community Benefit (ABCB) — Coverage Criteria for Home and Community-Based Services

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2014

Last ReviewFeb 23, 2015

Next Review DateFeb 23, 2015

Key ActionProviders must review prior authorizations for accuracy and contact the MCO immediately to correct any errors.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1115 waiverMedicaid authority for ABCB services

$3,500Community Transition limit

24/7Emergency Response availability

$5,000Environmental mod limit (5 yrs)

21+PCS minimum age

Coverage Criteria and Service Definitions

Covered Services (Adult Day Health, Assisted Living)

Covered services and service scope when provided by eligible, certified providers and incorporated into the member's Care Plan:

Adult Day Health Coverage Elements: Adult Day Health Services provide structured therapeutic, social and rehabilitative services as determined by the Plan of Care incorporated into the Care Plan; services are generally provided for two (2) or more hours per day on a regularly scheduled basis by licensed adult day care facilities; private duty nursing and skilled maintenance therapies may be provided in conjunction with Adult Day Health when delivered by licensed nurses and therapists and in a private setting at the facility; meals provided do not constitute a full nutritional regime; transportation to/from the center must be coordinated.>= 2 hours/day

Interdisciplinary team reviews at least quarterly; Plan of Care with goals and measurable objectives must be attached to or incorporated into the Care Plan.

Assisted Living Coverage Elements: Assisted Living provides a homelike residential environment with individualized services for ADLs and IADLs as identified in the Care Plan; services include 24-hour on-site response capability and ongoing supervision, direct services documented in a separate Assisted Living Plan of Care incorporated into the Care Plan, and coordination/access to services not provided directly by the facility; room and board costs are not reimbursed by ABCB.

Policy Summary

PayerNew Mexico Health Care Authority

PolicyAgency-Based Community Benefit (ABCB) — Coverage Criteria for Home and Community-Based Services

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2014

Last ReviewFeb 23, 2015

Next Review DateFeb 23, 2015

Key ActionProviders must review prior authorizations for accuracy and contact the MCO immediately to correct any errors.

SourceLink

On This Page

Behavior Support Consultation — Covered with criteria

Behavior Support Consultation is covered when ALL of the following are met

BSC initiation and authorization: Service is initiated when the MCO Care Coordinator identifies and recommends BSC units and includes them in the Care Plan; units must not exceed the capped dollar amount determined for the participant's Level of Care and Care Plan cycle.

Assessment requirement: BSC performs an initial comprehensive assessment for each participant; comprehensive assessment must be completed at least annually and when clinically indicated.

Provider qualifications: BSC services are provided within the professional scope of practice of a licensed BSC (licensed professionals as specified by state law); services include assessments, development of treatment plans, training, monitoring and consultation with IDT and medical providers.

Documentation and medical necessity: Provider must document assessment, care planning, interventions, progress and justification of medical necessity, including measurable goals; annual evaluation and updated treatment plan must be provided to the MCO Care Coordinator within 10 business days following the IDT meeting; progress/summary notes must include date, begin/end time, location, description of service, participant/family/DSP response, and plan for future service.

Community Transition Services — Covered with criteria

Community Transition Services are covered when ALL of the following are met

Member age and source: Member is an adult (21 years or older) transitioning from a skilled nursing facility to a community living arrangement where the member is directly responsible for ongoing living expenses.

Need and authorization: Expenses are necessary to enable establishment of a basic household, are reasonable and necessary as determined by the MCO, not available from other sources, and are authorized in the Care Plan and transition plan.

Exclusions and limits: Community Transition Services exclude monthly rent/mortgage, food, regular utilities and purely recreational items; services are limited to $3,500 per person every five years and require a minimum 90 continuous day nursing facility stay prior to transition.$3,500 per person every five years; >= 90-day NF stay

Emergency Response Services — Covered with criteria

Emergency Response Services are covered when ALL of the following are met

Service purpose and setup: Electronic monitoring systems are provided to secure help for members whose safety is at risk; covered components include installation, testing, maintenance, user training, 24/7 monitoring, monthly systems checks, and reporting member emergencies to the Care Coordinator; service must be included in the Care Plan.

Provider requirements: Emergency Response providers must comply with applicable New Mexico telecommunications/security laws, maintain financial reporting for each member, provide service/contract information to members, have security bonding, report emergencies/changes in member condition to the Care Coordinator within 24 hours, and complete quarterly member reports with originals maintained in the member's file.

Reimbursement and equipment: Reimbursement is based on negotiated rates with the MCO; billing is a monthly fee per calendar month of use; special equipment fees (Emergency Response - High Need) require medical necessity substantiated by the MCO.

Assisted Living / Agency Based Coverage rules

Assisted Living / Agency-based services coverage stance

Room and board: ABCB does not reimburse room and board costs (e.g., rent, groceries); providers must report room and board rates to HSD/MAD with enrollment and upon rate changes and comply with state/federal guidelines.

Non-billable activities: Assisted Living providers must not bill the MCO for room and board, general administrative training costs, or for individuals who are hospitalized or in institutional care settings.

Excluded service duplication: Assisted Living services do not include Personal Care, Respite, Environmental Modifications, Emergency Response or Adult Day Health to avoid duplication; those services are provided separately and must not be billed in addition to Assisted Living for the same needs.

Environmental Modifications - coverage criteria

Covered when ALL of the following are met

Environmental modification coverage conditions: Adaptation is identified in the member's Care Plan and is necessary to ensure the member's health, welfare, safety, or to enhance independence; adaptations exclude duplicate adaptations, general household repairs, and new construction for apartment buildings/assisted living; the MCO must document consideration and refusal of alternative funding sources prior to approval; provider must submit required pre- and post-construction documentation (including member-signed approval and photographs) and comply with building codes and property owner permission when applicable.project cost limits apply

Provider must follow technical oversight and submit Care Coordinator Individual Assessment of Need.

Financial limits and caps: Environmental modification projects are billed on a per-project basis (one unit per project) and are limited to $5,000 per member every five years; administrative costs for the project must not exceed 15% of the total project cost.<= $5,000 per 5 years; admin costs <= 15%

Employment Supports - coverage criteria

Supported employment services are covered when the following are met

Employment supports coverage: Member has a documented employment goal in the Care Plan and must utilize Vocational Rehabilitation services first; services facilitate integrated, competitive employment for individuals who need ongoing supports and are provided by qualified staff.

Service components and limits: Services include job development, employer negotiation, job restructuring, job sampling, placement, job coaching, coworker training, situational/vocational assessments and benefits counseling; payment covers adaptations and supports related to disability but excludes sheltered work, incentive payments, pass-through payments to program users, unrelated training, or business start-up/operating costs.

Staffing and reporting: Provider agencies must maintain vocational assessments, quarterly progress reports, Work/Learn Action Plan updates, and meet staffing requirements (for individual supported employment the staff:individual ratio is 1:1 unless Care Plan specifies otherwise) with a minimum one one-hour face-to-face visit per month for individual placements; billing is hourly and rounded to the nearest quarter hour and reimbursement is negotiated with the MCO.

Home Health Aide - coverage criteria

Home Health Aide services are covered when

HHA coverage conditions: Member requires assistance with ADLs or total care as defined (bathing, grooming, toileting, transfers, ambulation, nutrition); services are provided under RN or appropriate professional supervision with documented supervisory visits at least every two weeks; HHA personnel meet training/certification or competency standards per federal regulation 42 CFR 484.36 or state regulation 7 NMAC 28.2 and agency policies.

Agency responsibilities: HHA agency must be an approved HSD/MAD provider, document supervisory visits and HHA plan of care reviews annually/as needed, maintain monthly contact with the MCO Care Coordinator, and ensure RN supervisors have supervisory experience; physician orders that change services must be conveyed to the MCO Care Coordinator.

Scope of HHA tasks: Home Health Aides may perform basic noninvasive nursing assistant skills and assist with medications normally self-administered, provide bowel/bladder care, ostomy site care, ambulation/exercise assistance, household services essential to health care at home, report changes in patient condition, and complete appropriate records.

Emergency Response - coverage criteria

Emergency response coverage requirements

Eligibility and technical requirements: Eligible members must have a landline phone; provider must comply with state telecommunications/security regulations and maintain security bonding and financial reporting; response centers must be staffed by trained professionals.

Member information and reporting: Provider must provide members with service/contract information, report emergencies and condition changes to the Care Coordinator within 24 hours, and complete quarterly reports maintained in the member's file with copies to the MCO Care Coordinator.

Reimbursement and special equipment: Reimbursement is based on negotiated MCO rates and billed as a monthly fee per calendar month of use; special equipment (Emergency Response - High Need) requires medical necessity substantiated by the MCO.

Agency Certification & Operational Criteria

Covered when ALL of the following agency conditions are met

Certification and administrative requirements: Agency must be certified by Medicaid or its designee, maintain an official office and published hours and phone number, establish county service area(s), submit required packet (PPA/MAD-335, nationwide caregiver criminal history screenings, business license or nonprofit documentation, proof of liability and workers' compensation insurance), and attend mandatory provider training prior to furnishing PCS.

Policies, QA and operations: Agency must have written policies and procedures addressing PCS rules, personnel policies, operational details, and a quality improvement program including quarterly activities and documentation; agencies cannot be certified if ownership conflicts with assessors or other conflicts of interest.

Training and competency: Agencies must ensure required training and competency testing for attendants (including CPR/first aid, emergency response, infection control, documentation, and a competency test covering listed topics) and document personnel files and competency results.

Covered when criteria met

Covered when ALL of the following are met

Eligibility and need: Consumer is 21 years or older, eligible for full Medicaid benefits, and meets NF LOC criteria based on disability or functional limitation; PCS are allocated to avoid institutionalization and maintain ADL/IADL function.

Assessment requirement: MCO conducts a Comprehensive Needs Assessment (CNA) and functional assessment to determine the type and amount of PCS; CNA is performed at initial approval and at least annually or as needed; CNA informs IPoC development.

Service limits and duplication: PCS are not provided 24 hours/day, must not duplicate services from hospice, assisted living, home health, or other programs, and must supplement natural supports; services outside the residence require justification and prior approval.

PCS Agency Transfer - Approval Criteria

Transfers are consumer-initiated and require MCO approval. Covered when ALL of the following are met:

Transfer initiation: Transfer request must be initiated by the consumer or legal representative (not by attendant) using MAD 062 or approved form with consumer signature, receiving agency signature, date, and justification for transfer; consumer must state reason for transfer.

MCO review and timeline: MCO processes transfer requests within 15 business days of receipt, notifies consumer and both agencies of its decision within that timeframe, issues a new prior authorization and task information to the receiving agency if approved, and makes the transfer effective 10 business days from processing; originating agency remains responsible for services until transfer completion.15 business days; effective transfer 10 business days after processing

Eligibility and attendant checks: Requested attendant must have passed nationwide criminal history screening and not have been terminated from another agency for fraud/misconduct; MCO considers solicitation, agency compliance, and may audit agencies or impose corrective actions during review.

Consumer Discharge - Agency and State

Discharge is permitted for justifiable reasons; agencies must obtain MCO approval and provide notice. Covered when ALL of the following are met:

Notice requirement: PCS agency must submit notice to the MCO for approval prior to discharge; once approved the agency must provide 30-day written notice to the consumer stating the reason, appeal rights, and assist the consumer in transfer while continuing services through the discharge period.30 days

Justifiable reasons for discharge (examples): Examples include: staffing problems (e.g., excessive attendant change requests), pattern of verbal or physical abuse toward attendants or staff, uncooperative behavior/noncompliance with agency or Medicaid regulations, illegal narcotics or alcohol abuse, fraudulent timesheets, or unsafe/unhealthy living conditions that pose risk to staff or others.

Private Duty Nursing - Coverage Criteria

Private Duty Nursing is covered for adult members (21+) when ALL of the following are met:

Provider qualifications: Services must be provided by an RN or LPN with required skills and under a physician's order in accordance with the New Mexico Nurse Practice Act; clinical supervision by a Private Duty Nursing supervisor occurs in the member's home at least quarterly and supervision must be documented.

Orders and plan of care: A physician's order specifying the task, frequency, duration and individualized instructions is required for PDN services; a Plan of Care/Treatment (CMS form 485) separate from the MCO Care Plan must be developed, maintained in the member file and shared with the MCO; orders are obtained annually and when revising services and agencies must notify the MCO within 48 hours of physician-ordered changes.

Documentation and reporting: Comprehensive assessment/evaluation, initial and quarterly progress reports, documentation of complications, and supervision records must be maintained and submitted to the MCO; quarterly progress reports include assessment of status, health/safety issues, and progress toward goals.

Coverage Criteria

Covered when ALL of the following are met:

Core requirements: Services are within the scope of the NM Nurse Practice Act, provided under physician order, included on an authorized Care Plan/CCP and coordinated with the MCO Care Coordinator; medical necessity and justification for level/intensity must be documented (CMS-485 and physician orders).

Provider qualifications: PDN and respite staff must hold current NM licensure; agencies must be licensed/approved (Home Health Agency, RHC, FQHC or approved respite agency); supervisory RNs should have supervisory experience and staff must demonstrate competency for delegated programs.

Supervision and reporting: Clinical supervision by PDN supervisor/RN in-home at minimum quarterly; supervision and service changes must be documented and reported to the MCO within 48 hours; agencies submit initial and quarterly progress reports to the MCO and maintain rosters and utilization records.

Respite limits: Nursing Respite services provide short-term relief to a primary caregiver and are limited to a maximum of 100 hours per Care Plan year when a primary caregiver is present; for children/youth up to age 21 with a serious emotional or behavioral disorder, respite is limited to 720 hours per year or 30 calendar days; respite may not be provided by a member's spouse or household member and cannot be combined with Assisted Living in the CCP.100 hours/year; 720 hours/year or 30 days for eligible youth

Respite coverage criteria

Respite services are covered when the following limits and conditions are met

Respite general: Respite services are provided per negotiated MCO rate, billed hourly and rounded to the nearest quarter hour; providers must maintain cumulative utilization records and may require advanced notice for scheduling; members cannot schedule their own nursing respite with nursing respite staff.

Recipient and relationship exclusions: Respite services may not be provided by the member's spouse or household member; respite cannot be included in the CCP in combination with Assisted Living.

Annual limits (adult): Maximum 100 hours annually per Care Plan year when there is a primary caregiver; additional hours may be requested if health and safety needs exceed the specified amount.100 hours/year

Annual limits (children/youth): For children and youth up to 21 years with a serious emotional or behavioral disorder, respite services are limited to 720 hours per year or 30 calendar days.720 hours/year or 30 days

Skilled Maintenance Therapy coverage criteria

Occupational and Physical Therapy are covered when ordered and documented as medically necessary and meet provider, documentation, and service requirements

Age and provider: Therapy services are for individuals 21 years and older and must be provided by licensed therapists (OT or PT) as required by New Mexico law.age >=21

Referral/order: A signed referral/order from the member's Primary Care Physician specifying frequency, estimated duration, and treatments/procedures must be obtained and maintained in the member's file and shared with the MCO Care Coordinator.

Assessment and plan: Therapist must perform a comprehensive assessment, identify measurable short- and long-term goals, and document a treatment plan including frequency, estimated duration, treatments, member response and progress with dates and times.

Face-to-face and staffing: Therapy requires face-to-face contact for billable services (except where non-face-to-face consultation or assistive-technology development is allowed per reimbursement limits) and is provided 1:1 when actively delivering therapy.

Medical necessity and documentation: Clinical documentation must justify medical necessity and the level/intensity (frequency and duration) of therapy; providers must maintain assessment, plan, intervention and progress records and coordinate authorization with the MCO.

Service Codes, Units and Limits

Service codes and unitsmixed

S5100	Adult Day Health
T2031	Assisted Living
T2038	Community Transition Services
S5161	Emergency Response
S5161 U1	Emergency Response High Need
S5165	Environmental Modifications
H2019	Behavior Support Consultation
H2019TT	Behavior Support Consultation, Clinic Based
H2024	Employment Supports
S9122	Home Health Aide

1–10 of 20

1/2

Unit increments (mapping)mixed

S5100	1 unit = 15 minutes
T2031	1 unit = Month
T2038	1 unit = Per service
S5161	1 unit = Month
S5161 U1	1 unit = Month
S5165	1 unit = 1 unit per project
H2019	1 unit = 15 minutes
H2019TT	1 unit = 15 minutes
H2024	1 unit = Day
S9122	1 unit = Hour

1–10 of 20

1/2

Assisted Living billing unit

Billing unitDaily rate

Unit description (coding table)Assisted Living, CODE = T2031; UNIT INCREMENTS: 1 UNIT = Month (document states billable unit based on a daily rate)

Room & board exclusionRoom and board costs (rent, groceries, etc.) are not reimbursed by ABCB

Community Transition dollar limit

Dollar limit$3,500.00 per person every five years

Eligible useExpenses necessary to establish a basic household for transition (excludes rent, food, utilities, appliances, recreational items)

Prior stay requiredMember must have a nursing facility stay of at least 90 continuous days prior to transition

Community Transition facility stay

Minimum facility stayMinimum 90 continuous day nursing facility stay prior to transition

PurposeEligibility requirement to qualify for Community Transition Services

DocumentationMCO assessment must confirm prior NF stay and authorize transition goods/services

Environmental modification dollar limit

Dollar limit$5,000.00 every five years per project

ScopePhysical adaptations and environmental control systems to ensure health, welfare, safety, or independence (e.g., ramps, lifts, widened doorways)

ExclusionsGeneral household repairs, duplicate adaptations, or projects exceeding program limits are excluded

Environmental modification administrative cost cap

Administrative cost capAdministrative costs must not exceed 15% of the total environmental modification project cost

ApplicabilityCap applies to each project managed by the MCO

Risk of non-paymentRequests with administrative costs >15% risk non-payment

LOC approval duration

LOC approval durationMCO-approved nursing facility Level of Care (LOC) is valid for a maximum of 12 consecutive months

Re-determinationLOC must be re-determined at least annually or when a change in condition is identified

Prior authorization constraintPrior authorization for PCS cannot extend beyond the approved LOC period

Competency test passing threshold

Passing threshold>= 80% on the written competency test

TimingAttendant must pass within the first three months of employment

DocumentationA copy of the attendant's graded competency test indicating passing score must be maintained in the file

Supervisory visit frequency

Supervisory visit frequencyAgency must conduct face-to-face supervisory visits in the consumer's residence at least monthly (12 per service plan year)

Visit contentVisits must document date, time/length, reviewer name/title, individuals present, IPoC review, health/safety issues, and consumer/legal rep signature

HHA specificHome Health Aide agencies must make supervisory visits at least every two weeks to observe goals being met (per HHA requirements)

Annual respite hours (adult)

Adult annual respite hours100 hours maximum per Care Plan/CCP year (when there is a primary caregiver)

SettingsMay be provided in member's home, provider's home, or community; not by household member or spouse

Billing unitsBilled hourly and rounded to the nearest quarter hour per reimbursement rules

Annual respite hours (children/youth 621 with serious emotional/behavioral disorder)

Children/youth respite limit720 hours per year or 30 calendar days for children/youth up to 21 with serious emotional/behavioral disorder

Eligibility noteLimit applies to children/youth diagnosed with a serious emotional or behavioral health disorder as specified

ExclusionsRespite may not be provided by the member's spouse and cannot be combined with Assisted Living in the CCP

Unit increments

Standard unit increment15 minutes for many services (e.g., ADL-related services, therapy, BSC, PDN units)

Service-specific incrementsSome services use hourly, monthly, per-project, or per-day increments as specified (e.g., HHA = hour; Assisted Living = month; Environmental Modifications = 1 unit per project)

Rounding ruleRespite and therapy reimbursement billed hourly and rounded to nearest quarter hour per reimbursement guidance

Provider Responsibilities, Prior Authorization & Documentation

Billing Rule

Verify prior authorization and bill per MCO rates

Reimbursement is based on the negotiated rate with the MCO; providers must review prior authorizations issued by the MCO to ensure the information is correct and contact the MCO immediately to correct any errors. Billing for services is on an hourly/unit basis and time is accrued/rounded as specified (e.g., nearest quarter-hour where applicable).

Review each MCO prior authorization for accuracy before billing.
Contact the MCO immediately to correct any prior authorization errors.
Bill using the MCO-negotiated rates and the specified unit/rounding rules (e.g., nearest quarter hour where stated).

Prior Authorization

Confirm prior authorization details before providing care

Providers must ensure prior authorization information from the MCO is correct and contact the MCO immediately to have any errors corrected; reimbursement for services such as BSC, Community Transition, and Emergency Response is based on negotiated MCO rates and requires authorization.

Do not rely on prior authorization details without verification in the provider portal or documentation.
Notify the MCO immediately if authorization details (dates, units, service codes) are incorrect to avoid non-payment.

Prior Authorization

Verify PA and document alternative funding for environmental mods

For environmental modification and other services, providers must verify prior authorization details and demonstrate that alternative funding sources were considered and refused; contact the MCO immediately to correct any prior authorization errors.

Include documentation that insurance, workers' comp, vocational rehab, volunteer organizations, and other viable resources were contacted and refused.
Submit required pre-construction documentation (evaluation, cost estimate, photos, member acceptance, property owner permission) to the MCO with the PA.

Prior Authorization

Obtain and confirm MCO LOC approval (valid ≤12 months)

The MCO determines and approves nursing facility level of care (LOC) for PCS eligibility; LOC approvals are valid for up to 12 consecutive months and must be re-determined at least annually.

Obtain and confirm the MCO-issued LOC prior to furnishing PCS.
Request re-review if consumer's condition changes or if agency disagrees with the LOC determination.

Prior Authorization

Ensure PCS have MCO prior authorization tied to LOC

All Personal Care Services (PCS) require prior LOC approval and a prior authorization from the MCO; PCS authorizations cannot extend beyond the approved LOC period and are subject to utilization review for medical necessity.

Do not provide PCS without an MCO prior authorization tied to an approved LOC.
Understand that retroactive authorization is not allowed for PCS.

Prior Authorization

Follow MCO process for transfer prior authorization

When a PCS transfer is approved, the MCO will issue a new prior authorization number and task information to the receiving agency and make the transfer effective 10 business days after processing; the originating agency receives an ending authorization.

Submit the MAD 062 transfer form with required signatures and justification to initiate transfer.
Continue services as the originating agency until the transfer is complete.

Billing Rule

Review PAs for accuracy and bill per PA/rules

Providers must review prior authorization information for accuracy and contact the MCO immediately to correct any errors; reimbursement is based on negotiated MCO rates and billed per the stated unit and rounding rules (e.g., nearest quarter hour).

Verify PA dates, units, and authorized tasks before billing.
Bill per MCO instructions and rounding conventions to avoid claim denials.

Documentation Required

Obtain physician's order for Nursing Respite (scope & duration)

Nursing Respite services require a physician's order specifying the scope and duration; a new order is required for revisions and annually with Care Plan renewal, and the order must be obtained by the PDN agency and shared with the MCO.

Obtain and retain the physician's order in the member file and provide a copy to the MCO.
Update orders when services change and at each annual Care Plan renewal.

Billing Rule

Verify PA for respite/therapy and bill per negotiated rates

Respite and therapy reimbursement are based on negotiated MCO rates; providers must verify prior authorization accuracy and notify the MCO immediately of any errors to prevent non-payment; billing is on an hourly unit rate with rounding rules as specified.

Verify PA details for respite and therapy before providing services.
Bill using the MCO-negotiated hourly rate and apply the prescribed rounding (nearest quarter hour).

Prior Authorization

Provider responsibility to confirm PA accuracy

Providers are responsible to review prior authorization information for correctness and must contact the MCO to correct errors; accurate authorizations are required for reimbursement which is based on negotiated rates.

Confirm PA contains correct service codes and units prior to delivering services.
Notify the MCO immediately if discrepancies are found to avoid denials.

Step Therapy

Document assessed need and least-intrusive steps for residential modifications

Any modification to residential conditions (e.g., assisted living Plan of Care modifications) must be supported by an assessed need, document less intrusive alternatives tried, include informed consent, time-limited reviews, data collection, and assurance interventions will cause no harm.

Document assessed need and interventions tried before implementing modifications.
Obtain informed consent and set periodic review time limits to assess necessity and effectiveness.

Prior Authorization

Initiate BSC only when MCO Care Coordinator includes units in Care Plan

Behavior Support Consultation services are initiated when the MCO Care Coordinator identifies and includes recommended units in the Care Plan; the Care Coordinator and participant must ensure units do not exceed capped dollar amounts for the participant's LOC and Care Plan cycle.

Do not initiate BSC without inclusion of recommended units by the MCO Care Coordinator in the Care Plan.
Monitor that provided units remain within the LOC-based capped dollar amount.

Step Therapy

Document other funding sources before requesting ABCB services

ABCB services are payer of last resort: providers and MCOs must explore and document other third-party or community resources (insurance, workers' comp, vocational rehab, volunteer organizations) before ABCB services are requested or authorized.

Document contacts with other potential funders and evidence they were unavailable/refused.
Do not request ABCB authorization until other viable payment sources have been exhausted.

Note

Provide PCS in residence and avoid duplication of other program services

Providers must comply with service location rules: PCS are usually furnished in the consumer's residence and must not duplicate services available through other programs (home health, hospice, assisted living); services outside the residence require justification and prior approval.

Confirm the member is not already receiving the same services through another program before authorizing PCS.
Obtain MCO justification and approval for any services delivered outside the residence.

Billing Rule

Bill usual and customary charges per MCO billing instructions

Reimbursement is based on the negotiated rate with the MCO; agencies must bill their usual and customary charge and follow MCO billing specifications when submitting claims for PCS.

Ensure the agency's billed charge reflects the usual and customary charge for the service.
Follow MCO billing instructions to prevent payment delays or recoupments.

Step Therapy

ABCB is payer of last resort — document third-party options

ABCB is payer of last resort: other third-party and community resources and third-party liability must be explored and accessed before ABCB services are requested or authorized.

Verify and document that third-party sources were considered prior to requesting ABCB funding.
Access third-party liability when available before billing ABCB.

Step Therapy

Do not request OT until other payers/resources exhausted

Occupational therapy services should not be requested or authorized until other third-party and community resources have been explored and exhausted; occupational therapy is provided with the MCO as payer of last resort.

Document attempts to secure other reimbursement sources before submitting OT authorization requests.
Share third-party exhaustion documentation with the MCO as part of the authorization packet.

Step Therapy

Document exhaustion of third-party/community resources before ABCB requests

ABCB services should not be requested or authorized until all other third-party and community resources have been explored/exhausted; the MCO is the payer of last resort and providers must document attempts to access alternative payment sources.

Maintain documentation that other viable funding sources were contacted and unavailable.
Submit evidence of exhaustion of alternatives with authorization requests.

Documentation Required

Maintain licenses and forward POC to MCO Care Coordinator

Providers must have and maintain required licenses and documentation of Care Plans and Plans of Care (POC) incorporated into the member's Care Plan; providers must forward POC and agreements to the MCO Care Coordinator and retain originals in member files.

Keep originals of POCs and provider agreements in the member's file and provide copies to the MCO Care Coordinator.
Ensure provider enrollment and certification with HSD/MAD before rendering ABCB services.

Documentation Required

Follow HSD/MAD documentation standards and timely submission to MCO

Behavior Support Consultation and other program providers must complete documentation per HSD/MAD and federal guidelines: entries must include document title, participant name, date, signature with credentials, and BSC must provide the annual evaluation and updated treatment plan to the MCO Care Coordinator within 10 business days following the IDT meeting.

Ensure all notes include date, begin/end times, location, description of service, participant/family/DSP response, and plan for future service.
Provide the annual evaluation and updated treatment plan to the MCO Care Coordinator within 10 business days after IDT.

Documentation Required

Maintain ER financial reports and report emergencies to Care Coordinator within 24 hours

Emergency Response providers must maintain financial reporting for each member, provide members information about services/limits/contracts, have security bonding, report emergencies or condition changes to the Care Coordinator within 24 hours, and complete quarterly member reports with originals retained in the member file and copies to the MCO Care Coordinator.

Report emergencies and condition changes to the Care Coordinator within 24 hours.
Maintain original quarterly reports in the member file and submit copies to the MCO Care Coordinator.

Documentation Required

Submit required pre- and post-construction documents for environmental mods

For environmental modifications, providers must submit pre-construction documentation to the MCO including an environmental modification evaluation, cost estimate with photographs and dates, member's acceptance letter, property owner permission, and construction letter of understanding; after completion submit member-signed approval and photos.

Provide the MCO with the environmental modification evaluation and detailed cost estimate with photos and start/completion dates.
Obtain and submit member acceptance and property owner permission letters before starting work; submit signed approval and completion photos after work is finished.

Documentation Required

Maintain confidential case files with quarterly reports and competency records

Supported Employment and Home Health Aide providers must maintain confidential case files that include quarterly progress reports, vocational assessments or task lists, Work/Learn Action Plan updates, supervisory visit documentation, and records of staff training and competencies.

Retain quarterly progress reports and vocational assessments in each participant's case file.
Document supervisory visits and staff competency training as required.

Documentation Required

Provide members service/contract info and submit quarterly reports to MCO

Emergency Response providers must provide members with information about services, limits, and agency contracts; maintain original quarterly reports in the member file and submit copies to the MCO Care Coordinator; report emergencies/condition changes to the Care Coordinator within 24 hours.

Give each member written information about services rendered, limits, and contacts for problems.
Keep originals of quarterly reports in the member file and send copies to the MCO Care Coordinator.

Documentation Required

Keep personnel files and document supervisory visits and eligibility verifications

Maintain personnel files with HHA/CNA training and competency documentation; document supervisory visits/contacts in the member's clinical file using standardized forms; verify Medicaid eligibility monthly and retain verification date and method.

Document RN supervisory visits at least once every two weeks for HHAs and retain the supervisory form in the member's clinical file.
Keep personnel files showing training and competency testing and record monthly Medicaid eligibility verification.

Documentation Required

Retain records 6 years and submit transfer/closure form after 90 days

Agencies must maintain consumer and attendant files for at least six years, keep documentation of training, competency testing, approvals, signed IPoC and timesheets/logs; logs must be auditable and compared to timesheets; submit MAD 062 transfer/closure form after 90 consecutive days without services or upon death.

Retain consumer and attendant records for a minimum of six years.
Submit a MAD 062 transfer/closure form when the consumer has not received services for 90 consecutive days or upon death.

Documentation Required

Submit MAD 062 with required signatures and justification for transfers

Transfer requests must include a completed MAD 062 (or approved form) with the consumer's signature, date, receiving PCS agency signature, and justification for the transfer.

Ensure the MAD 062 contains the consumer's signature and the receiving agency's signature and a clear justification.
Submit the completed form to the MCO to initiate transfer processing.

Documentation Required

Obtain physician order and maintain CMS-485 for PDN

Private Duty Nursing requires a written physician's order specifying tasks, frequency, duration, and individualized instructions; a Plan of Care/Treatment (CMS form 485) separate from the MCO Care Plan must be developed, maintained in the member's file, and shared with the MCO.

Obtain and keep the physician's order and CMS-485 in the member's file and provide copies to the MCO.
Update and share revised orders with the MCO within 48 hours of physician-ordered changes.

Documentation Required

Keep comprehensive assessments and documentation to justify medical necessity

Providers must perform a comprehensive assessment/evaluation and maintain clinical records that support medical necessity, level and intensity (frequency and duration), plan of care (CMS-485), physician orders, and quarterly progress reports; documentation must be available and supervision recorded.

Keep comprehensive assessments and quarterly progress reports in the member's clinical record.
Document supervision and ensure records justify billed frequency and duration.

Documentation Required

Maintain records that justify medical necessity and billed services

Providers must maintain records of services, personnel training, fiscal accountability, and clinical documentation justifying medical necessity for services and the frequency/duration billed; documentation must support authorized Care Plan services.

Retain documentation that clinical services billed are reflected and authorized in the Care Plan.
Ensure fiscal records satisfy the Medicaid Provider Participation Agreement (MPPA).

Documentation Required

Obtain and retain signed therapy referral/order from PCP

A signed therapy referral/order from the member's primary care physician (including frequency, estimated duration, and treatments) must be obtained and maintained in the member's file and shared with the MCO Care Coordinator before therapy services begin.

Obtain and file the physician's referral/order prior to initiating OT/PT/SLP services.
Share the referral/order with the MCO Care Coordinator and retain a copy in the member's file.

Documentation Required

Provide face-to-face therapy (1:1) except where non-face-to-face is allowed

Therapy services require face-to-face contact except where non-face-to-face consultation or individualized assistive-technology development is allowable per reimbursement limits; face-to-face therapy is provided 1:1 when actively delivering therapy.

Document face-to-face sessions and provide 1:1 staffing during active therapy time.
Limit non-face-to-face activities to those explicitly allowed and within reimbursement limits.

Documentation Required

Document clinical role and medical necessity for billed services

Providers must maintain clinical documentation identifying their role in assessment, care planning, interventions, communications, and evaluation, and must justify medical necessity for the service and intensity in each member's clinical record.

Ensure notes clearly show clinician's contribution to assessment, plan, and progress.
Retain documentation that supports billed frequency and duration for review or audits.

Documentation Required

Retain PCP-signed referral/order and share with MCO for skilled therapy

Obtain and keep a signed referral/order from the member's Primary Care Physician in the member's file and share it with the MCO Care Coordinator for speech therapy and other skilled therapies as required.

File the PCP order in the member's record and provide a copy to the MCO Care Coordinator.
Ensure therapy reports are current and available upon HSD/MAD request.

Note

Complete HSD/MAD enrollment and certification before providing ABCB services

Providers must be approved and certified by HSD/MAD Long Term Care provider enrollment unit before rendering ABCB services; incomplete enrollment applications will be rejected until complete.

Complete HSD/MAD provider enrollment and maintain required licenses and approvals.
Do not deliver ABCB services before HSD/MAD approval and certification.

Denial Risk

Do not bill for non-billable BSC activities

Non-billable BSC activities (errands, friendly visiting, financial brokerage, administrative paperwork/travel, transportation, pickup/delivery of commodities, and other non-Medicaid reimbursable activities) will not be authorized for payment by HSD/MAD.

Do not bill HSD/MAD or the MCO for non-professional BSC duties listed as non-billable.
Ensure BSC documentation focuses on assessments, treatment plans, training, and clinical activities that are billable.

Denial Risk

Correct PA errors immediately to avoid non-payment

Providers must review prior authorization information for correctness and contact the MCO immediately to correct errors; failure to have correct prior authorization information could risk non-payment or denial of claims.

Confirm PA details (service, units, dates) before delivering services.
Document communications with the MCO when correcting PA errors.

Denial Risk

Do not exceed $5,000 per 5 years or >15% admin costs for environmental mods

Environmental modification requests that exceed $5,000 per five years or include administrative costs exceeding 15% of the project cost risk non-payment and will not be approved.

Ensure project cost estimates do not exceed $5,000 within a 5-year period.
Keep administrative costs at or below 15% of the total project cost.

Denial Risk

Verify LOC and full Medicaid eligibility to avoid PCS denials

Members not meeting NF level of care, receiving other conflicting Medicaid HCBS waiver benefits or institutional services, or not having full Medicaid eligibility at the time services are furnished can result in ineligibility or denial of PCS.

Verify member has full Medicaid eligibility before providing PCS and document monthly verification.
Confirm member is not concurrently receiving excluded waiver benefits, NF, ICF/IID, PACE, or APS attendant care.

Denial Risk

Be aware of transfer denial triggers and required timelines

Transfers may be denied for multiple reasons (consumer requesting more hours/services, request initiated by attendant/family, three or more transfers in six months, requested attendant lacking criminal history clearance, attendant terminated for fraud, attendant refusing mandated trainings, consumer noncompliance, or suspected solicitation); the MCO will notify parties within 15 working days.

Ensure transfers are initiated by the consumer or legal representative and include valid justification.
Confirm requested attendant has passed nationwide criminal history screening before requesting transfer.

Denial Risk

Transfer denials may be issued for listed reasons—follow MAD 062 rules

The MCO may deny a consumer-requested transfer for specific reasons including requests from an attendant or family member, consumer requests for more hours/services, repeated transfer requests, requested attendant lacking criminal history clearance, or prior termination for fraud; providers should ensure transfer forms and justifications meet MCO requirements.

Complete MAD 062 accurately and include consumer signature and receiving agency signature.
Do not initiate transfers on behalf of the attendant; transfers must come from the consumer or legal representative.

Denial Risk

Non-billable activities will not be authorized or paid

Services that are non-billable (errands, friendly visiting, financial brokerage, administrative paperwork/travel, transportation, pickup/delivery of commodities, and other non-Medicaid reimbursable activities) will not be authorized for payment.

Do not include non-billable activities in claims or prior authorization requests.
Ensure training billed is member-specific; general training is administrative and not billable.

Prior Authorization

Verify PA accuracy; correct errors promptly to reduce denial risk

Providers must review prior authorization information for accuracy and contact the MCO immediately to correct any errors; failure to have correct prior authorization information may risk non-payment or denial.

Document PA verification steps and any communications with the MCO regarding corrections.
Correct PA errors before billing to reduce the risk of claim denials.

Denial Risk

Insufficient clinical documentation risks denial or non-payment

Services lacking clinical documentation that justifies medical necessity for the service, level, frequency, or duration may lead to non-payment or denial; providers must document assessments, care plans, interventions, and progress to support billed services.

Maintain assessments, physician orders, treatment plans, and progress notes that support billed frequency and duration.
Ensure documentation evidences the clinical rationale for each billed service.

Definitions and Key Terms

Clinical Necessity

DefinitionHealth care services that a healthcare provider, exercising clinical decisions on behalf of an individual, result in necessary, safe, effective, and appropriate clinical services consistent with diagnosis and provider scope of practice.

Clinical judgementIncludes decisions considering severity/complexity of symptoms and appropriate interventions

Scope requirementDecisions must be rendered in accordance with the provider's professional license or scope of practice regulations in the state where the provider practices

Care Plan / Plan of Care

DefinitionA procedural plan describing specified activities and oversight to safeguard the individual's health; the Health Care Plan is developed and monitored by a nurse and is incorporated into the member's Care Plan. Plan of Care (CMS form 485) is used for Private Duty Nursing as a separate POC to the MCO Care Plan.

ContentSpecifies activities, oversight, frequency and is used to coordinate services with the MCO Care Coordinator

DocumentationPOC and Care Plan documents must be maintained in member file and shared with MCO Care Coordinator

Behavior Support Consultant (BSC)

DefinitionA Behavior Support Consultant (BSC) is a licensed professional as specified by applicable State laws and standards who provides assessments, evaluations, treatments, interventions, follow-up services and training to participants, families, and direct support professionals.

ServicesIncludes comprehensive assessment, treatment planning, measurable goals, training and follow-up; documentation must be provided to MCO Care Coordinator within 10 business days after IDT meeting

QualificationsMust meet applicable state licensure standards (e.g., licensed psychologist, LISW, LMSW, LPCC, LMFT as appropriate)

Environmental Modifications definition

DefinitionPhysical adaptations and environmental control systems (excluding durable medical equipment) identified in the Care Plan to ensure the member's health, welfare, safety, or enhance independence (examples: ramps, widened doorways, specialized plumbing/electrical, lifts, bathroom modifications, mobility tracks, automatic door openers, alarm systems, air filtration, heating/cooling adaptations).

Project unitEnvironmental Modifications billed as 1 unit per project (coding: S5165)

LimitsServices limited to $5,000 every five years and administrative costs capped at 15% of total project cost

Home Health Aide (HHA) Services definition

DefinitionHome Health Aide (HHA) Services provide total care or assist an eligible member in all activities of daily living, including bathing, grooming, toileting, transfers, ambulation, nutrition assistance, and some basic noninvasive nursing assistant skills provided under RN or appropriate professional supervision.

SupervisionHHA services must be provided under RN or appropriate professional supervision with supervisory visits at least every two weeks

Coding/unitHHA code = S9122; unit increment = hour

Personal Care Services (PCS) definition

DefinitionPersonal Care Services (PCS) are Medicaid services providing ADL and IADL assistance to consumers age 21 or older who meet nursing facility Level of Care to maintain function and avoid institutionalization; delivered pursuant to an Individual Plan of Care (IPoC) and determined via a Comprehensive Needs Assessment (CNA).

PurposeIntended to supplement natural supports and avoid duplication of other programs like home health or hospice

EligibilityRecipient must be full-benefit Medicaid, age >=21, and meet NF LOC determined by MCO

Consumer-directed vs Consumer-delegated models

Consumer-directedConsumer oversees service delivery and uses a PCS agency as a fiscal intermediary for payroll/financial paperwork

Consumer-delegatedAgency performs employer tasks and is responsible for ensuring service delivery on behalf of the consumer

Choice and explanationMCO Care Coordinator must explain both models to consumers initially and annually

Mobility assistance

DefinitionMobility assistance is assistance with ambulation, transferring, or repositioning, defined as moving inside or outside the residence with or without assistive devices, or changing position to prevent skin breakdown.

ContextsMay be provided during administration of any PCS task and may include physical assistance or verbal prompting and cueing

Relation to ADLsMobility assistance is integral to ADL support provided by attendants or HHAs

Ability to self-administer (medication)

DefinitionAbility to self-administer medication: the ability to identify and communicate medication name, dosage, frequency, and reason; certain PCS are provided only when the consumer has this ability.

ImplicationConsumers who cannot self-administer are not eligible for certain PCS tasks involving medications

AssessmentAbility assessed during CNA and documented in the IPoC

Private Duty Nursing definition

DefinitionPrivate Duty Nursing (PDN) provides intermittent or extended direct nursing care in the member's home for adults (21+), delivered by RN or LPN under a written physician's order and accompanied by a Plan of Care/Treatment (CMS form 485).

Concurrent care exclusionPDN and Medicare/Medicaid skilled nursing may not be provided at the same time

DocumentationPhysician orders and CMS-485 POC must be maintained in member's file and shared with the MCO

Primary caregiver

DefinitionPrimary caregiver: the individual identified in the Care Plan or Comprehensive Care Plan who assists the member on a frequent basis (daily or at minimum weekly); not required to reside with the member to be eligible for respite.

Role in respitePresence of a primary caregiver is a condition for standard respite limits (100 hours/year)

IdentificationPrimary caregiver is recorded in the Care Plan/CCP

Skilled Maintenance Therapies definition

DefinitionSkilled Maintenance Therapies: Occupational, Physical, and Speech/Language therapies for individuals 21+ focused on maintenance and functional support as an extension of therapy provided for acute/temporary conditions.

Provider orderAll services must be under the order of the member's Primary Care Physician and referrals/orders must be kept in member file and shared with the MCO Care Coordinator

StaffingTherapy delivered 1:1 when providing active therapy; PTAs and OTAs may perform tasks under supervision per Plan of Care

Qualified provider

Qualified provider - PTGraduation from an accredited physical therapy program and current New Mexico licensure; PTAs may perform procedures under supervision per Plan of Care

Qualified provider - SLTSpeech-language therapists must hold a master's or doctoral degree, ASHA CCC, and New Mexico licensure

Administrative requirementsProviders must adhere to HSD/MAD requirements (OSHA, criminal background checks, financial reporting) and have access to necessary diagnostic/therapeutic materials

Agency-Based Community Benefit (ABCB) — Coverage Criteria for Home and Community-Based Services

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Coverage Criteria and Service Definitions

Service Codes, Units and Limits

Provider Responsibilities, Prior Authorization & Documentation

Program Background and Scope

Definitions and Key Terms

Policy Revision History