Health Care Professional Services — General Benefit Description
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State Medicaid (MAD) rules describing covered professional health care services, limits, prior authorization, and program administration for MAP eligible recipients in New Mexico.
No material clinical or coverage changes in this revision.
Coverage Criteria and Service Limits
General coverage principle
Covered when ALL of the following are met
Claims are subject to pre- or post-payment review and recoupment.
Transplant coverage
Non-experimental transplant services are covered when ALL of the following are met
Prior authorization must be started by the attending PCP contacting the MAD UR contractor.
Reproductive and obstetric services
Covered when ALL of the following are met
Consent forms and documentation requirements specified; see 42 CFR Section 441.251 et seq.
BOP is limited to uncomplicated pregnancies and requires providers to be enrolled and act within scope of practice.
Laboratory, imaging, and dental coverage limits
Covered when specific service rules are met
Reimbursement includes necessary materials and minor services; certain contrast agents may be paid separately.
Replacement of a sealant within 60 months requires prior authorization; many services limited by age and clinical criteria.
Preventive dental services (age-differentiated)
Covered when ALL of the following age-based conditions are met:
Dental radiology
Covered with specified frequency limits:
Endodontic services (pulpotomy)
Covered when ALL of the following are met:
Routine foot care / podiatry coverage
Covered when specified systemic conditions and severity/class findings are present and active care by a physician or PA is documented:
Medical justification must be documented in the medical record.
Dental adjunctive services (anesthesia and behavior management)
Covered when medical necessity and documentation requirements are met:
Providers must retain documentation to substantiate medical necessity.
Anesthesia coverage limits
Covered when medically necessary but bundled in some cases:
Exceptions exist for higher-intensity anesthesia or when specified by policy.
Client medical transportation (CMT) coverage
Covered when medically necessary and documentation/authorization requirements met:
Verification of eligibility and certification required for CMT fund advances.
Documentation requirements apply for attendants and mileage.
Lodging initially authorized up to five continuous days with re-evaluation for extensions.
Telehealth / Telemedicine
Covered consistent with in-person Medicaid coverage when technology and licensure requirements are met:
If audio/video is used when patient and practitioner are co-located, bill as face-to-face and telemedicine reimbursement does not apply.
Telemedicine Services Coverage
Covered when ALL of the following are met
If audio/video technology is used when patient and practitioner are in the same institutional or office setting, bill as in-person encounter.
Fee reimbursed at the lesser of billed charge or MAD maximum; recipient not reimbursed for personal computer/internet.
Store-and-forward encounters are asynchronous and do not require live face-to-face encounter.
Pregnancy Termination Coverage
Covered when ANY one of the following provider-certified conditions is met
Consent valid for 30 calendar days unless withdrawn; emergency exceptions apply.
Providers must complete and retain consent and documentation in the medical record; behavioral health referral options exist.
Experimental/Investigational Services
Not covered unless specified
MAD may request providers to present evidence that a technology is not experimental or investigational.
Tobacco Cessation Coverage
Covered services and conditions
Pharmacists providing cessation services must have attended a continuing education course on tobacco cessation.
Documentation of tobacco use and counseling must be maintained by the provider.
Providers must document medical necessity and that counseling was prescribed.
Medical Necessity and Authorization
Covered when medically necessary and prior authorization obtained if required
Services are subject to utilization review before, during, or after payment; prior authorization must be obtained and approved where required and does not guarantee payment or eligibility.
MAD does not cover procedures intended to reverse sterilization or hysterectomy when performed solely for family planning. For surgical sterilization or hysterectomy that does result in sterility, providers must obtain and attach a signed voluntary informed consent or hysterectomy acknowledgment/consent meeting the criteria in 42 CFR Section 441.251 et seq., including age, competency and non-institutionalized status at the time consent is obtained. Services that are not medically necessary for the MAP eligible recipient as determined by MAD or its designee are also not covered.
MAD excludes services and items furnished solely for aesthetic or cosmetic purposes. Specific noncovered dental services include permanent fixed bridges, implants and implant-related services, procedures solely for aesthetic purposes (such as tooth bleaching, veneers, mastique), occlusal adjustments and certain prosthetic procedures, and services provided by non-certified dental assistants. Cosmetic services and surgeries more broadly are not covered unless the procedure meets specific criteria and is approved as medically necessary reconstructive surgery.
MAD may coordinate payments with Medicare and will not reimburse for services that Medicare denies based on Medicare coverage limitations. Providers must pursue applicable Medicare coverage before requesting MAD reimbursement when coordination of benefits applies.
MAD does not cover elective pregnancy termination procedures. Pregnancy termination services are payable only when a provider certifies in writing that the procedure meets one of the specified clinical conditions (for example, necessary to save the life of the MAP eligible recipient) and a signed consent and written certification are filed in the recipient's medical record.
Telemedicine is not payable as a telemedicine encounter when interactive audio/video technology is used while the MAP eligible recipient and the practitioner are co-located in the same institutional or office setting; in those situations the service must be billed as an in-person encounter and no additional telemedicine originating-site reimbursement is made.
MAD does not reimburse for medical, surgical, or other health care procedures, including drugs, devices, or treatments, that are considered experimental or investigational. A technology is experimental/investigational when authoritative evidence shows that further studies are needed, it lacks final regulatory approval, or it is the subject of ongoing phase I–III clinical trials. On request, MAD or its designee may require a provider to present current, authoritative evidence that a proposed technology is not experimental. An exception exists for routine patient care services rendered during participation in qualifying cancer clinical trials; MAD may reimburse routine care services that would otherwise be covered.
MAD does not pay for services provided to a surrogate mother under a surrogacy agreement or contract when those services relate to the surrogate pregnancy (including prenatal care, delivery, postpartum care, or complications of pregnancy).
A service is covered only when it is medically necessary for the MAP eligible recipient as determined by MAD or its designee. Medical necessity determinations consider the specific service, level of care, and setting. Claims and services remain subject to utilization review before, during, or after payment, and MAD may deny payment or recoup funds if a service is determined not to be medically necessary.
Routine foot care is noncovered except when the recipient meets the specified systemic condition and class-finding criteria. Examples of noncovered routine foot care include trimming, cutting, clipping and debriding toenails; cutting or removal of corns, calluses, or hyperkeratosis; other hygienic and preventative maintenance care such as cleaning, soaking, topical skin creams, and application of topical medications when performed in the absence of localized illness, injury or symptoms; and any service performed without localized foot disease.
MAD excludes cosmetic items and services prescribed or used for aesthetic purposes. Cosmetic surgeries performed solely for aesthetic reasons are not covered. MAD covers only reconstructive surgery that meets specific criteria and is approved as medically necessary.
MAD may deny payment when a service is determined not to be medically necessary or not to be a covered MAD service. Determinations made after payment are subject to recoupment. Providers may request reconsideration of prior authorization denials or other review decisions and may pursue administrative hearings if not satisfied with reconsideration outcomes.
Service Frequency, Limits, and Coding-Related Rules
Authorization, Documentation, and Billing Responsibilities
Prior authorization required for transplants
A written prior authorization must be obtained for any transplant except cornea and kidney; the prior authorization process must be started by the MAP eligible recipient's attending PCP contacting the MAD UR contractor.
Prior authorization when service limits are exceeded
Exceeding the stated service frequency limits (for example, office visits, physical medicine modalities/procedures, and manipulations) requires prior authorization before furnishing additional services.
- Examples of limits: one office visit per day from same provider/group; three physical medicine modalities/procedures per month; three manipulations per month.
Prior authorization for inpatient dental and out-of-state transport
Prior authorization is required for dental services performed in an inpatient hospital setting unless the recipient is under 21 or hospitalization for the procedure is medically justified; out-of-state transportation, meals and lodging must be prior approved by MAD or its designee.
- Inpatient dental services require prior authorization except when recipient is under 21 or inpatient hospitalization is medically justified.
- Out-of-state transportation, meals and lodging require prior approval and justification that care is not available in New Mexico.
Sealant replacement requires prior authorization
Replacement of a dental sealant within the 60-month period requires prior authorization before the service is furnished.
- Sealants for permanent molars are limited to one treatment per tooth every 60 months; replacement inside that period needs PA.
Prior authorization requirement for specified services
Certain procedures and services may require prior authorization from MAD or its designee; many dental services and most transplant services require prior authorization and must be approved before services are furnished.
- Prior authorizations specify approved units and dates and do not guarantee recipient eligibility or payment.
- Providers must verify recipient eligibility at the time services are furnished.
Obtain prior authorization before service delivery
Some procedures and services require prior authorization from MAD or its designee and prior authorization must be obtained and approved before services are furnished; services remain subject to utilization review even after prior approval.
- A prior authorization specifies the approved number of service units and the dates the service must be provided.
- Approval does not guarantee eligibility; providers must verify MAD eligibility at time of service.
Retroactive prior authorization — limited exceptions
A retroactive prior authorization may be approved in limited circumstances (e.g., as part of eligibility determinations for institutional or HCBS waiver programs, when services were furnished before determination of effective MAD eligibility or provider participation, or in medical emergencies); requests based on retrospective eligibility must be submitted in writing within 30 calendar days of the eligibility determination.
- Retroactive PA for provider/recipient eligibility must be received in writing within 30 calendar days of the eligibility determination.
- Medical emergencies are an allowable reason for retrospective prior authorization.
Coordinate with Medicare before requesting MAD payment
MAD may coordinate payments with Medicare; providers must pursue Medicare coverage where applicable before requesting MAD reimbursement (for example in transplant/ESRD contexts).
- After Medicare payment, MAD may pay coinsurance, deductible, and copayment subject to MAD limits; providers may not collect excess from the recipient.
No step therapy requirements
Step therapy is not described in this section; no step therapy sequences are specified.
Tobacco cessation products — no prior authorization
Tobacco cessation products do not require prior authorization for reimbursement but must be prescribed by a MAD-enrolled practitioner and counseling must be documented.
- Eligible pharmacists must have completed at least one CE course on tobacco cessation.
- Providers must maintain documentation of tobacco use and counseling.
Attach signed consent for sterilization/hysterectomy
Signed voluntary informed consent acknowledging sterilizing results must be completed and attached to the claim/kept in the recipient's medical record for sterilization and hysterectomy procedures; consent requirements vary in emergency or other circumstances.
- Consent must meet age, competency, and non-institutionalization criteria described in rule.
- Providers must retain original signed consent in the recipient's medical records.
Document medical justification for hospital procedures
Medical justification for performing procedures in a hospital (rather than outpatient setting) must be documented in the MAP eligible recipient's medical record.
- Claims for outpatient procedures performed in a hospital are subject to pre-payment or post-payment review and require documentation of medical justification.
Retain documentation for CMT reimbursement
For client medical transportation (CMT) reimbursement, providers must retain written verification of appointments, receipts, referrals stating services unavailable locally, eligibility verification, mileage, and justification for a medical attendant; referrals for travel over 65 miles must include the out-of-community provider name and justification that care is not available locally.
- CMT fund reimbursement requests must be submitted within 30 calendar days of appointment or hospital discharge.
- Written referral for out-of-community service must be received no later than 30 calendar days from the appointment date for fund advances.
Maintain anesthesia medical necessity documentation
When general anesthesia or IV sedation is used for dental care, documentation of medical necessity must be available for review by MAD or its designee.
- Nitrous oxide analgesia is covered for recipients under 21 but not for recipients 21 and older.
File signed consent for pregnancy termination
Providers must complete and file a signed informed consent for pregnancy termination in the recipient's medical record, including written certification that the procedure meets one of the specified provider-certified conditions; retain the original signed consent in the medical record.
- Consent is valid for 30 calendar days from signature unless withdrawn.
- Exceptions to parental consent for minors and emergency circumstances are specified.
Obtain and follow UR instructions from HSD/MAD
Providers must contact HSD or its authorized agents to request utilization review (UR) instructions, access and understand UR documents and instructions, comply with requirements, and follow coordinated services contractor authorization processes when applicable.
- Providers are responsible for obtaining hard copies if needed and for ensuring compliance with UR instructions.
- When billed to a coordinated services contractor, follow that contractor's authorization instructions.
Be prepared for payment review and verify provider eligibility
Claims are subject to pre-payment or post-payment review and recoupment; reimbursement is contingent on the provider being eligible for MAD participation at the time services are furnished.
- MAD does not cover services furnished when the provider or facility did not meet required licensing or certification at the time services were furnished.
Document medical justification for inpatient claims
Claims for outpatient procedures performed in a hospital require medical justification documented in the medical record whenever hospitalization is used instead of an outpatient setting; lack of justification may lead to denial or recoupment.
- Medical justification should explain why hospitalization was necessary (e.g., pre-existing conditions that predispose recipient to complications).
Transportation denial triggers — avoid non-covered travel claims
Transportation payments for services that are not covered by MAD are subject to retroactive recoupment; payment for an attendant is not allowed without the required certification from the recipient's medical or behavioral health provider.
- Transportation to a non-covered MAD service and minor children accompanying the recipient are not covered.
- Providers must ensure required certifications for attendants are documented to avoid denial.
Services subject to UR and prior authorization
Services are subject to utilization review (UR) for medical necessity and program compliance; prior authorization may be required for specified procedures and services and obtaining prior authorization does not guarantee payment.
- UR may occur before, during, after, or post-payment; providers must cooperate with MAD or its designee in any review.
- A prior authorization specifies approved units and dates but services remain subject to later UR determinations.
Denial and recoupment risk for non-medically necessary or non-covered services
MAD may deny payment if a service or procedure is not medically necessary or not a covered MAD service; denials before payment result in claim denial and denials after payment are subject to recoupment.
- Providers may request reconsideration of prior authorization denials or other review decisions and may pursue administrative hearing rights as specified.
Policy Background
MAD covers medically necessary services for diagnosis and treatment of illness or injury for MAP eligible recipients and limits services by frequency, medical necessity, and provider scope of practice. Coverage is determined by MAD or its designee and services are subject to utilization review and payment review; reimbursement is contingent on provider eligibility at the time services are furnished.
Key Definitions
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