HEALTH CARE PROFESSIONALS MEDICAID GENERAL BENEFIT DESCRIPTION
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
State rule describing Medicaid (MAD) coverage, limitations, provider requirements, and covered services for MAP eligible recipients in New Mexico; governs enrolled providers and impacts reimbursement, prior authorization, and service limits.
No material clinical or coverage changes in this revision.
Coverage Criteria and Limits
inv-01: General medical necessity and provider enrollment
Covered when ALL of the following are met
Claims are subject to pre-payment or post-payment review and recoupment.
inv-02: Medicare coordination
MAD payment interactions with Medicare
Special rules apply when MAD uses encounter rates, percent of billed charges, or other non‑equivalent methodologies.
inv-03: Frequency limits
Coverage subject to frequency limits; prior authorization required to exceed
Exceeding requires prior authorization.
Exceeding requires prior authorization.
Exceeding requires prior authorization.
inv-04: Dental frequency limits
Dental diagnostic, radiology and preventive services limits
Emergency oral examinations are covered when performed to relieve pain and suffering.
Series includes bitewing x‑rays.
inv-05: Reproductive health coverage and exclusions
Covered reproductive services and required consents
Forms and informed consent requirements per federal and state rules.
inv-06: Dental preventive services
Covered when ALL of the following are met (age-dependent limits):
inv-07: Dental radiology
Covered when meeting frequency limits:
Includes bitewing x‑rays.
inv-08: Endodontic services
Covered when ALL of the following are met:
inv-09: Periodontic services
Covered when specific provider and authorization conditions are met:
inv-10: Adjunctive general services
Covered when medical necessity is documented:
For recipients under 21, nitrous oxide analgesia is covered; for recipients 21 and older nitrous oxide is not covered.
inv-11: Hospital dental services
Inpatient dental services covered only with prior authorization unless:
Documentation of medical necessity must be available for review.
inv-12: Routine foot care
Routine foot care is covered only when ALL of the following are met:
A CNP, PA or CNS do not satisfy the 'active care by a PCP' requirement for some diagnoses.
Class A: non‑traumatic amputation; Class B: absent pulses or advanced trophic changes; Class C: claudication, temperature changes, edema, paresthesias, burning.
inv-13: Podiatry exclusions
Not covered when performed for these isolated or cosmetic purposes:
inv-14: Vision services
Covered when meeting age-based frequency limits or medical condition documentation:
Medical condition must be documented on the visual exam record.
inv-15: Client medical transportation
Covered when medically necessary and no free or less costly alternatives exist:
Authorization forms available through local ISD offices.
Reusable items and oxygen included in base rate.
Detention/standby beyond one hour requires statement from attending provider or flight nurse.
inv-16: Lodging and meal services
Covered when travel for MAD services requires overnight stay or extended travel time:
Authorization based on attending provider's statement of need.
Authorization forms available through local ISD offices.
inv-17: Transportation, lodging, and attendant coverage
Covered when ALL of the following are met
Out‑of‑state lodging authorizations may be granted up to 30 calendar days and re‑evaluated every 30 days.
inv-18: Attendant and waiver recipient transport
Covered when ALL of the following are met
MAD only covers attendant costs when certified in writing.
inv-19: Telemedicine coverage
Covered when ALL of the following are met
Reimbursement parity for originating and distant sites; distant‑site provider licensing rules apply when outside New Mexico.
inv-20: Transplantation services
Covered when ALL of the following are met
Providers must pursue Medicare eligibility for kidney transplants related to end‑stage renal disease before requesting MAD reimbursement.
inv-21: Pregnancy termination
MAD will pay for pregnancy termination only when ONE of the following conditions is met and certified in writing by the provider
Provider must submit written certification and obtain informed consent; special consent rules apply to minors and emergency situations.
inv-22: Experimental and clinical trial coverage
Covered when ALL of the following are met
MAD will not reimburse experimental or investigational procedures except as specified for qualifying cancer clinical trials; providers may be asked to provide evidence that a technology is not experimental.
inv-23: Smoking cessation services
Covered when ALL of the following are met
No prior authorization required for tobacco cessation products; counseling limits apply.
inv-24: Tobacco cessation counseling (pregnant/postpartum)
Covered when ALL of the following are met
Session durations defined as intermediate (>3 to 10 minutes) or intensive (>10 minutes).
inv-25: Cessation counseling limits
Coverage subject to stated session limits
inv-26: Medical necessity
Covered when medically necessary
Providers must verify coverage and medical necessity prior to furnishing services.
MAD does not cover certain reproductive services. Specifically, MAD excludes sterilization reversal services, fertility drugs, in vitro fertilization, artificial insemination, and hysterectomies performed for the sole purpose of family planning. In addition, MAD excludes induced vaginal deliveries prior to 39 weeks unless medically indicated, cesarean sections unless medically indicated, and elective procedures to terminate a pregnancy.
MAD does not separately cover certain laboratory and radiology ancillary items and limits professional component payment. Specimen handling, mailing, and certain specimen collection fees are not covered, and MAD does not pay for specimens conveyed to a second non‑certified laboratory. For diagnostic imaging, only one professional component is paid per radiological procedure, and professional components are not paid when the same provider or provider group bills both the professional component and the performance of the complete procedure.
MAD excludes pharmacy items that lack effectiveness or are available through public health programs and excludes personal care or cosmetic pharmacy items. Specifically, MAD does not cover drug items classified as ineffective by the FDA, antitubercular drugs available from the public health department, or pharmacy items used solely for cosmetic purposes. The policy also states that transportation to a pharmacy is not a MAD allowed benefit.
MAD considers certain services not medically necessary and therefore non‑covered. Examples include dietary counseling provided solely for weight loss, commercial weight control or weight management programs, and commercial dietary supplements or replacement products marketed primarily for weight loss. The dental section further enumerates aesthetic or cosmetic dental procedures and several restorative items as noncovered when not medically necessary.
MAD excludes routine foot care and many orthopedic shoe/supportive device claims unless strict criteria are met. Routine foot care such as trimming or debriding toenails, removal of corns and calluses, hygienic maintenance, and similar services performed in the absence of a localized illness or qualifying systemic condition are not covered. Services directed at correction of flat foot and most orthopedic shoes and supportive devices are generally not covered unless the shoe is integral to a leg brace or is a therapeutic diabetic shoe.
MAD does not reimburse transportation for noncovered services or to pharmacies, and attendant or companion transport is limited by certification requirements. Providers must verify recipient eligibility and certify that free alternative transportation services are not available. MAD also excludes payment for penalties related to missed appointments, interest or carrying charges, and other non‑medical ancillary expenses.
MAD excludes a broad set of cosmetic, non‑diagnostic, and routine services. Cosmetic items and surgeries for purely aesthetic purposes are not covered, as are hair or nail analysis, telephone consultations, and many preparations dispensed for home use unless specifically authorized. Routine physical examinations are covered only for residents of nursing facilities or ICF‑IID settings; routine screening services not used to make a diagnosis are also excluded.
MAD does not pay for services provided to surrogate mothers when there is an agreement or contract between the surrogate and another party for pregnancy, prenatal, postpartum care, or delivery. Such services are specifically excluded under the general noncovered services provisions.
Services that are not considered medically necessary for the recipient's condition as determined by MAD or its designee are not covered. MAD reserves the right to deny payment for services lacking medical necessity and to recoup payments when retrospective review determines the service was not medically necessary for the specific service, level of care, or setting.
Dietary counseling provided exclusively for weight loss and commercial weight‑loss products are not covered because they are not considered medically necessary. MAD limits nutrition services to assessments and counseling furnished by PCPs, licensed nutritionists, or licensed dietitians and excludes programs or products marketed primarily for weight loss.
Routine foot care performed in the absence of a localized illness, injury, or qualifying systemic condition is considered not medically necessary and is therefore not covered by MAD. Coverage of routine foot care is limited to recipients who meet documented systemic condition and class finding criteria and when medical justification is recorded in the recipient's medical record.
Procedures, drugs, devices, or treatments considered experimental or investigational are not covered. MAD may approve routine patient care costs associated with participation in qualifying phase I–IV cancer clinical trials that meet federal agency approval and IRB review requirements, but otherwise experimental interventions are excluded and providers may be asked to provide authoritative evidence that a technology is not experimental.
Services that are not medically necessary for the specific service, level of care, or setting will be denied. MAD conducts prepayment, concurrent, and retrospective reviews, and when a service is found not to be a covered MAD benefit or not medically necessary, payment may be denied or recouped. Providers must verify coverage and medical necessity prior to furnishing services.
Billing Codes, Frequencies, and Key Values
| E&M | Evaluation and management service codes may be used to bill for assessing tobacco dependence and written cessation plan of care. |
Provider Requirements, Prior Authorizations, and Documentation
Prior authorization required to exceed frequency limits
Exceeding the specified frequency limits (office visits, physical medicine modalities/procedures/kinetic activities, and manipulation/OMT/myofascial release) requires prior authorization from MAD or its designee before providing services that exceed the stated limits.
- Office visits: limited to one per day from the same provider or provider group; prior authorization required to exceed.
- Physical medicine modalities/procedures/kinetic activities: limited to three per month from the same provider or provider group; prior authorization required to exceed.
- Manipulation/OMT/myofascial release: limited to three manipulations per calendar month; prior authorization required to exceed.
Prior authorization for inpatient dental services and extended lodging
Prior authorization must be obtained for dental services performed in an inpatient hospital setting except when the recipient is under 21 or has a documented medical justification for hospitalization; lodging beyond initial authorization also requires prior authorization and re-evaluation.
- Inpatient dental services: prior authorization required unless recipient is under 21 or has documented medical justification.
- General anesthesia/IV sedation and inpatient procedures: documentation of medical necessity must be available for review.
- Lodging beyond initial authorized period requires prior authorization and re-evaluation.
Prior approval required for out-of-state travel and related expenses
All out-of-state transportation, meals, and lodging must be prior approved by MAD or its designee; out-of-state medical or behavioral health services are approved only if MAD or its designee has approved the out‑of‑state service and supporting documentation verifying lack of in‑state availability is provided.
- Requests for out-of-state transportation must be coordinated through MAD or its designee.
- Documentation must justify that treatment is not available in New Mexico.
Lodging initial authorization and re-evaluation requirements
Lodging is authorized initially for up to five continuous days when medically justified; extensions require re-evaluation prior to expiration and authorization is re-evaluated every 15 calendar days for extended stays.
- Initial lodging authorization: up to five continuous days based on attending provider's statement of need.
- For stays beyond five days, re-evaluate to authorize up to an additional 15 days and then every 15 calendar days thereafter prior to expiration.
Obtain prior authorization for listed services
Certain services require prior authorization from MAD or its designee; prior authorization must be obtained before furnishing services and specifies approved units and dates—examples include some dental/orthodontic services and most transplants (except cornea and kidney).
- Dental services: some diagnostic, preventive, restorative, endodontic, periodontic, prosthodontic, oral surgery, and orthodontic services require prior authorization.
- Transplantation services: written prior authorization required for any transplant except cornea and kidney.
- A prior authorization does not guarantee recipient eligibility and remains subject to utilization review.
General provider enrollment, UR cooperation, and payment requirements
Providers must comply with general MAD obligations: enroll as MAD providers, verify recipient eligibility, cooperate with utilization review, and supply required payment information (EFT) to receive reimbursement.
- Provider must be a MAD enrolled provider and meet licensing/certification at time services are furnished.
- Providers must cooperate with MAD or its designee in utilization review (pre-, concurrent, pre-payment, retrospective).
- MAD issues payments via electronic funds transfer; providers must supply necessary information for payment.
Transportation authorization: certify lack of free alternatives and use least-cost option
Transportation coverage requires certification that free alternatives are not available and that the least costly appropriate transportation alternative is used before more expensive options; providers must obtain required verifications for travel over 65 miles.
- Recipient must certify in writing that free alternatives (volunteers, relatives, facility-provided transport) are not available.
- For travel over 65 miles, transportation provider must retain written verification from the referring or service provider showing the service, out‑of‑community provider name, and justification that care is not available in the home community.
Tobacco cessation drugs: no PA but prescription by MAD-enrolled prescriber required
Tobacco cessation pharmacotherapy does not require prior authorization but must be prescribed by a MAD‑enrolled practitioner; eligible pharmacists must meet training requirements to render cessation services.
- No prior authorization required for reimbursement of tobacco cessation products, but items must be prescribed by a MAD enrolled practitioner and dispensed by a MAD enrolled pharmacy.
- Eligible pharmacists must have attended at least one continuing education course on tobacco cessation per federal guidelines.
Document medical justification and obtain informed consent for sterilization/hysterectomy
Document medical justification in the recipient's medical record for outpatient procedures performed in a hospital when hospitalization is not otherwise necessary; sterilizations and hysterectomies require signed voluntary informed consent acknowledging sterilizing results (with limited exceptions).
- Medical justification for performing outpatient procedures in a hospital must be documented in the recipient's medical record.
- Hysterectomies require a signed, voluntary informed consent acknowledging sterilization results; certain exceptions apply (previous sterilization or past child-bearing age).
Keep medical necessity documentation available for anesthesia/sedation and inpatient dental services
Maintain documentation of medical necessity for services such as general anesthesia and intravenous sedation and make it available for MAD review; prior authorization is required for inpatient hospital dental services except specified exceptions.
- Documentation of medical necessity for general anesthesia and IV sedation must be available for review by MAD or its designee.
- Inpatient hospital dental services require prior authorization unless the recipient is under 21 or has a documented medical justification.
Retain written verification for CMT fund reimbursement and long-distance travel
For CMT fund reimbursements or travel over 65 miles, retain written verification from the referring or service provider showing the service, out‑of‑community provider name, and justification that care is not available in the home community; submit appointment confirmations and receipts as required.
- Transportation provider must obtain and retain written verification for travel over 65 miles including service type, out‑of‑community provider name, and justification.
- CMT fund advances for emergencies must be requested and disbursed prior to the appointment and eligibility and appointment must be verified by the ISD custodian or contractor.
Document patient participation for telemedicine and record tobacco cessation prescriptions/counseling
For telemedicine system fee reimbursement, document that the originating-site patient was present and participated; for tobacco cessation, maintain documentation substantiating medical necessity and that counseling was prescribed by a MAD‑enrolled practitioner.
- Originating-site system fee paid only if the MAP eligible recipient was present and participated in the telemedicine visit and the system meets the telemedicine definition.
- Ordering and rendering practitioners must maintain documentation of tobacco use and that face‑to‑face counseling was prescribed by an enrolled practitioner.
Submit written certification and retain consent/counseling records for pregnancy termination
Submit and retain written certification and signed informed consent for pregnancy termination services that meet MAD's specified conditions; keep counseling documentation and follow special consent rules for minors.
- Provider must submit written certification with billing that the procedure meets one of MAD's permitted conditions (e.g., life‑saving, rape/incest, ectopic, severe health impact).
- Keep original signed consent and counseling referral information in the recipient's medical record; special parental consent rules apply for non‑emancipated minors.
Maintain counseling and cessation service documentation to substantiate medical necessity
Maintain sufficient documentation to substantiate medical necessity and services rendered for counseling and cessation services, including documentation of tobacco use and that face‑to‑face counseling was prescribed by an enrolled practitioner.
- Ordering and rendering practitioners must keep records that justify medical necessity and document services rendered.
- Rendering practitioner must document that face‑to‑face counseling was prescribed even if the case is a referral to self.
Follow provider participation agreement, UR instructions, and EFT payment requirements
Adhere to the MAD provider participation agreement and supply required payment information (EFT); providers must also access and follow UR instructions and program materials provided by MAD or its designees.
- Providers must follow UR instructions and obtain answers to any questions from MAD or authorized agents.
- MAD issues payments via EFT; providers must provide necessary information for electronic payment.
Expect utilization review and potential recoupment for non‑medically necessary services
Claims are subject to pre‑payment or post‑payment review and potential recoupment; ensure services are medically necessary and within provider licensing/scope to avoid denial or recoupment.
- MAD may perform prior authorization review, concurrent review, pre-payment review, or retrospective review at any time.
- If MAD determines a service was not medically necessary after payment, payment is subject to recoupment or repayment.
Denial risk for services not medically necessary (e.g., weight‑loss counseling)
Services determined not medically necessary by MAD or its designee (for example, dietary counseling solely for weight loss, weight management programs, or commercial weight‑loss products) may be denied; providers should document medical necessity to mitigate denial risk.
- Examples of services that may be denied as not medically necessary include dietary counseling solely for weight loss, weight control/management programs, and commercial dietary supplements marketed for weight loss.
- Providers should verify and document medical necessity prior to furnishing services.
CMT fund and travel documentation: 30‑day retention and recoupment risk
Failure to provide required written referral or out‑of‑community documentation within 30 calendar days for travel/CMT fund claims can trigger denial and recoupment proceedings; retain appointment confirmations and receipts as required.
- For travel over 65 miles, retain written verification from the referring or service provider with service details and justification that care is not available locally.
- CMT fund reimbursements require timely documentation; failure to supply documentation may result in recoupment.
Denial/recoupment risk if out‑of‑state travel not prior approved or justified
Out‑of‑state transportation, meals, and lodging must have prior approval from MAD or its designee; lack of prior approval or missing justification that care is unavailable in‑state can lead to noncoverage or recoupment.
- Authorization for out‑of‑state lodging/meals can be granted for up to 30 calendar days and re-evaluated every 30 days thereafter.
- Providers must coordinate requests through MAD or its designee and provide documentation that treatment is not available in New Mexico.
Denial and recoupment risk for non‑covered or non‑medically necessary services
MAD may deny payment if a service is not medically necessary or not a covered MAD service; if lack of medical necessity is identified after payment, MAD may recoup funds and providers may request reconsideration or an administrative hearing.
- Provider may request reconsideration of prior authorization denials and subsequent administrative hearings if dissatisfied with determinations.
- Payments determined to be for non‑medically necessary services are subject to recoupment.
Background and Scope
Background: MAD covers medically necessary services for diagnosis and treatment of illnesses, injuries, or conditions for MAP eligible recipients. Coverage requires that services be medically necessary, furnished by a MAD‑enrolled provider, and within the provider's scope of practice and applicable rules. MAD coordinates payments with Medicare where applicable and subjects claims to utilization review and potential recoupment if services are not covered or lack medical necessity.
Definitions
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.