Health Care Professional Services — General Benefit Description
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Governs Medicaid (MAP) coverage, limits, and administrative requirements for medically necessary professional health care services provided to MAP eligible recipients in New Mexico; applies to providers and the general public seeking to understand covered services, limitations, and prior authorization rules.
Coverage rules, limits, and exclusions
General coverage criteria and limits
Covered when ALL of the following general rules are met:
Claims are subject to pre‑payment or post‑payment review and recoupment.
Exceeding these limits requires prior authorization.
Preauthorization, concurrent, prepayment, retrospective and other UR reviews may be applied.
Consent and related forms must be retained in the medical record and supplied with the claim as required.
Reimbursement for midwife services is based on a global fee that may include prenatal, delivery and postpartum care.
Certification process includes application, review committee and appeal procedures.
Medicare eligibility must be pursued for kidney transplants when applicable; services with prior authorization remain subject to UR.
Dental coverage (diagnostic, preventive, restorative, hospital)
Covered dental services with limits and age‑based rules:
Emergency oral examinations are covered; replacement of a sealant within 60 months requires prior authorization.
Sealants not covered if occlusal restoration completed on the tooth; sealant replacement within 60 months requires prior authorization.
Collaborative practice dental hygienists may provide certain periodontic procedures under diagnosis by a MAD‑enrolled dentist; periodontal maintenance may require prior authorization.
Prior authorization requirements are waived for true emergencies (claims still subject to review).
Podiatry coverage and exclusions
Podiatry and routine foot care coverage and limits:
Treatment of plantar warts and mycotic nails may be covered under specified conditions.
MAD will not reimburse for services denied by Medicare for coverage limitations.
Orthopedic shoes covered only when integral to a leg brace or for diabetic therapeutic shoes as specified.
Vision
Vision coverage:
Non‑covered vision services include those furnished for cosmetic or aesthetic purposes; orthoptics are covered only when medically necessary.
Transportation, lodging, meals, attendants
Client medical transportation (CMT), ambulance, air transport, lodging, meals and attendant coverage:
Failure to provide required documentation may trigger recoupment; members enrolled in an HSD contracted MCO are not eligible to use the CMT fund for MCO‑responsible services.
Emergency defined by the prudent layperson standard and includes risks to pregnant individuals and unborn child when applicable.
Out‑of‑state travel requires prior approval and documentation that the service is not available in New Mexico.
Transportation and related expenses are limited to the recipient and certified attendant only; minor children accompanying the recipient without certification are not covered.
Anesthesia
Anesthesia coverage rules:
Documentation of medical necessity must be available for review by MAD or its designee; for some lower‑intensity anesthesia provided by the procedure provider (e.g., local/topical), payment is considered bundled with the procedure and not payable separately.
Anesthesia services for procedures that are not MAD‑covered services are not covered.
Pregnancy termination — covered conditions and consent
MAD will pay for pregnancy termination services only when one of the following conditions is met and required consent/documentation is on file:
A provider must certify in writing which condition applies and that the procedure meets that condition.
Required acknowledgements must include alternatives to termination, description of the procedure, potential risks and side effects, right to behavioral health services and the right to withdraw consent up to the time the procedure is performed.
Telehealth coverage and modalities
Telemedicine and telehealth services are covered consistent with in‑person services when definitions and technology requirements are met:
When the originating‑site is in New Mexico and the distant‑site is outside New Mexico, the distant‑site provider must be licensed for telemedicine as required by New Mexico law, unless federal exceptions apply.
Telemedicine services remain subject to the same program restrictions and are not covered when audio/video technology is used while patient and practitioner are in the same institutional or office setting.
Experimental or investigational services
MAD does not cover experimental or investigational procedures except under specified clinical trial circumstances:
MAD may reimburse routine patient care costs for participation in qualifying cancer clinical trials (phase I–IV) that meet specified federal approvals and IRB review criteria.
On request, providers may be required to present authoritative evidence that a proposed technology is not experimental or investigational.
Tobacco cessation
MAD covers tobacco cessation medications and counseling with specific provider and documentation requirements:
Products must be prescribed by a MAD‑enrolled practitioner.
Ordering and rendering practitioners must maintain documentation to substantiate medical necessity and that counseling was prescribed by a practitioner.
Medical necessity and utilization review
Covered only when medically necessary and subject to utilization review:
Services determined not medically necessary will be denied and payments may be recouped; UR may occur prior to, during, or after service delivery.
A prior authorization does not guarantee eligibility or future payment.
Prior authorization
Prior authorization requirements and constraints:
Retroactive prior authorization may be approved only in limited, specified circumstances (e.g., eligibility determination processes, medical emergencies, certain Medicare denial situations) and approved services remain subject to utilization review and potential denial or recoupment.
Prior authorization requirements are waived for emergency care (claims remain subject to review to confirm emergency).
MAD does not cover procedures or services related to fertility restoration or assisted reproduction. Specifically, the program excludes sterilization reversal services, fertility drugs, in vitro fertilization, and artificial insemination. In addition, hysterectomies performed solely for family planning and elective procedures to terminate a pregnancy are not covered. Providers must follow existing consent and documentation rules when sterilization or hysterectomy services are furnished and attach signed voluntary informed consent forms to the claim where required.
MAD covers midwife services within the scope of applicable program limitations but specifically excludes certain items and practitioners. Non-covered midwife services include oral medications and other pharmacy preparations and items that the MAP eligible recipient can appropriately self-administer (for example, ointments, creams, suppositories, ophthalmic and otic preparations). Services furnished by an apprentice midwife are not covered unless billed by the supervising midwife; similarly, use of an assistant at a home birth is not covered unless medical necessity is documented. Midwife and birth center facility services are reimbursed separately when provided through a DOH-licensed birth center enrolled in the BOP program.
MAD covers medically necessary laboratory and diagnostic imaging services ordered by an enrolled PCP, PA, CNP or CNS and performed by enrolled laboratories or hospital labs; however, several laboratory-related items are not reimbursable. Specimen handling, mailing, and collection fees are not covered except where specifically indicated. Specimen collection fees are payable only when the specimen is obtained by venipuncture, arterial stick, or urethral catheterization from an outpatient (not a nursing facility or inpatient). In addition, routine clinical laboratory professional components are limited to the specific covered circumstances described under the laboratory coverage rules.
MAD does not cover services provided solely for aesthetic or cosmetic reasons. This includes routine cosmetic dental and vision procedures and other items prescribed for appearance rather than function. Examples include cosmetic restorations or procedures, certain oral preparations for home use unless authorized by MAD, and non-prescription personal care items (lotions, shampoos, sunscreens) used purely for appearance. In dental care this extends to services such as permanent fixed bridges, implants and implant-related services when performed for cosmetic purposes. These exclusions apply unless the procedure meets MAD's established criteria for medical necessity and reconstructive surgery.
Podiatric services are reimbursed when medically necessary and within the scope of MAD rules; however, routine foot care and many elective podiatric items are excluded. Routine foot care—defined as trimming, cutting or debriding toenails; removal of corns or calluses; hygienic maintenance such as cleaning or soaking; and other services performed in the absence of localized illness or symptoms—is not covered unless the recipient meets specified systemic condition class findings. MAD also generally excludes services intended solely to correct flat foot, most orthopedic shoes and supportive devices (except when integral to a leg brace or for therapeutic diabetic shoes), and surgical or nonsurgical correction of a subluxated foot structure when performed as an isolated condition.
Vision services are covered when medically necessary and per age-based frequency rules, but MAD does not pay for services provided for cosmetic or aesthetic purposes. Routine eye examinations are limited to one every 36 months for adults ≥21 and one every 12 months for recipients <21. Orthoptics and orthoptic treatments are reimbursable only when specific medical necessity criteria are met and documented on the examination record and claim.
MAD covers transportation for medically necessary services but excludes certain attendant and travel costs. An attendant is covered only when required and certified by the recipient's medical or behavioral health provider; MAD does not cover attendants without the required certification or minor children who simply accompany the recipient. Transportation to a non-covered MAD service is not reimbursable and is subject to retroactive recoupment. CMT fund advances and reimbursements must follow documentation and timing rules to avoid recoupment.
Out-of-community travel, lodging and meal requests must be prior approved when required and are supported only when documentation shows the service is not available in-state. For CMT fund advances, written referral or supporting documentation must be provided within 30 calendar days of the appointment; failure to provide required documentation will trigger recoupment. Recipients enrolled in an HSD-contracted MCO are not eligible to use the CMT fund for services that are the MCO's responsibility.
MAD maintains an enumerated list of noncovered service categories. Examples include cosmetic services and items for aesthetic purposes, postmortem examinations, and most formal educational or vocational services (with limited exceptions related to ICF-IID or inpatient psychiatric treatment for recipients under 21). MAD also excludes hair or nail analysis and routine physical examinations except for specific populations identified in policy.
Telemedicine services are reimbursable when they meet program definitions and technology requirements; however, MAD explicitly excludes telemedicine encounters in which audio/video technology is used while the MAP eligible recipient and the practitioner are located in the same institutional or office setting. Telephone-only services and store-and-forward are reimbursable within their defined limits, but telemedicine-originating site fees require the recipient to be present in the originating-site meeting the telemedicine system definition.
MAD aligns noncoverage determinations with Medicare where Medicare has determined a service is not medically necessary or is experimental; in such cases, MAD will not pay for the same service. Specifically, services not covered by Medicare due to non-medical necessity or experimental status are excluded from MAD coverage. Retroactive prior authorization requests that follow a Medicare denial must include the Medicare denial documentation and MAD will not cover services Medicare denied for lack of medical necessity.
Services determined by MAD or its designee to be not medically necessary are not covered. This includes certain reproductive and elective services outlined in the exclusions (for example, elective pregnancy terminations and procedures not meeting medical indication). Providers must verify medical necessity prior to furnishing services, and medical necessity determinations are made by professional peers using established criteria; payments for services later found not medically necessary are subject to recoupment.
Routine cosmetic dental and vision procedures are considered not medically necessary and are not covered. Many elective podiatric services and orthopedic shoe items are also excluded unless they meet specified medical necessity criteria. Likewise, elective dental implants and certain prosthodontic services performed for cosmetic reasons are not reimbursable unless medical necessity criteria are satisfied and documentation supports coverage.
MAD does not cover services that Medicare excludes because they are not medically necessary or are considered experimental. Providers should assume services denied or classified as experimental by Medicare will likewise be noncovered by MAD unless MAD specifically authorizes coverage under an applicable exception.
If MAD or its designee determines after payment that a service was not medically necessary or not a covered MAD benefit, payment will be denied or recouped. Retrospective review may result in recoupment of previously paid claims when records do not validate that the service was performed, was covered, or met medical necessity criteria. Providers must retain required documentation and respond to utilization review requests to avoid recovery actions.
Coding, frequency limits, and code notes
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Prior authorization, documentation, and recoupment — actions providers must take
Get prior authorization for exceeded limits and transplants
Obtain prior authorization before exceeding any stated frequency limits; obtain written prior authorization for any transplant (except as noted for contacting the MAD UR contractor).
- Exceeding service frequency limits requires prior authorization.
- A written prior authorization must be obtained for any transplant; the prior authorization process must be started by the MAP PCP contacting the MAD UR contractor (cornea and kidney transplants excepted in some rules).
- Services for which prior approval was obtained remain subject to utilization review.
Prior authorization for inpatient dental/anesthesia
Obtain prior authorization for dental services performed in an inpatient hospital setting unless the recipient is under 21 or has a documented medical condition justifying hospitalization; outpatient services that require prior authorization also require it when performed inpatient.
- Prior authorization is required for dental services performed in an inpatient hospital setting except when the MAP eligible recipient is under 21 or under-21 with documented medical justification.
- Any service that requires prior authorization outpatient must have prior authorization if performed inpatient.
Prior authorization required for sealant replacement within 60 months
Request prior authorization before replacing a molar sealant if the prior sealant was placed within the last 60 months.
- Replacement of a sealant within the 60-month period requires prior authorization.
- MAD does not cover sealants for recipients 21 years of age and older.
Follow prior authorization requirements for specified services
Obtain prior authorization from MAD or its designee for specified services (including many dental services and most transplants); note that pregnancy termination services do not require prior authorization.
- Certain dental services and transplantation services require prior authorization from MAD or its designee.
- A written prior authorization must be obtained for any transplant (exceptions and contact processes specified).
- Pregnancy termination services do not require prior authorization.
Submit prior authorization requests to MAD/designee and document approvals
For other procedures and services that require prior authorization, submit requests to MAD or its designee and ensure approvals specify units and dates; approved authorizations remain subject to utilization review and eligibility verification.
- Prior authorization approvals specify the approved number of service units and the dates the service must be provided.
- Prior authorizations remain subject to utilization review and verification of eligibility at time of service.
Retroactive prior authorization allowed only in limited situations
Retroactive prior authorization may be approved only in limited circumstances (eligibility determinations for certain programs, services furnished before effective date when requested within 30 days, medical emergencies, or specific Medicare denial scenarios); submit retro requests in writing with required documentation.
- Requests for retroactive prior authorization must be received in writing by MAD or its designee within 30 calendar days in specified situations.
- Retroactive approval may be granted for eligibility determination processes, when service preceded determination of effective date with timely request, in medical emergencies, or when Medicare denied payment for reasons other than medical necessity (documentation required).
Step therapy not specified
No step therapy rules are specified in this document; there are no step therapy requirements stated in these sections.
- The policy does not impose step therapy requirements in the sections reviewed.
No step therapy; tobacco cessation prescriptions do not require prior auth
No step therapy requirements apply here; tobacco cessation drug items do not require prior authorization but must be prescribed by a MAD-enrolled prescriber.
- Tobacco cessation products are covered without prior authorization but must be ordered by a MAD enrolled prescriber and dispensed by a MAD enrolled pharmacy.
Prescribe tobacco cessation products as a MAD-enrolled prescriber
Prescribe tobacco cessation medications only if you are a MAD-enrolled prescriber; maintain documentation of the prescription and counseling as required.
- Tobacco cessation drug items do not require prior authorization but must be ordered by a MAD-enrolled prescriber and dispensed by a MAD-enrolled pharmacy.
- Ordering and rendering practitioners must maintain documentation to substantiate medical necessity and that face-to-face counseling was prescribed when applicable.
Attach signed sterilization/hysterectomy consent to claim
Attach signed voluntary informed consent (sterilization consent or hysterectomy acknowledgment) to the claim before performing sterilization or hysterectomy; ensure all consent requirements are met and documented.
- Prior to performing surgical procedures that result in sterility, providers must complete a sterilization consent/hysterectomy acknowledgment form.
- Recipients must be given information about the procedure, risks, benefits, and the right to withdraw consent prior to the procedure.
Document anesthesia medical necessity and retain for review
Maintain documentation of medical necessity for general anesthesia and IV sedation and make it available for review by MAD or its designee; nitrous oxide coverage for recipients under 21 requires medical justification documentation.
- Documentation of medical necessity must be available for review for general anesthesia and intravenous sedation.
- MAD covers nitrous oxide analgesia for recipients under 21; for recipients 21 and older nitrous oxide analgesia is not covered.
Supply required CMT documentation within 30 days
For CMT fund reimbursements, provide written receipts with dates of service, original-signature referrals when required, eligibility verification, certification that free alternatives were unavailable, mileage verification, and justification for attendants within 30 calendar days.
- MAP eligible recipients must apply for CMT reimbursement within 30 calendar days from the date of appointment or hospital discharge.
- Information to furnish includes written receipts confirming date of service, proper referral with original signatures when necessary, verification of current eligibility, certification that free alternatives are not available, mileage verification, and documentation justifying a medical attendant.
Get prior approval and justify out-of-state travel and lodging
Obtain prior approval for out-of-state transportation, lodging, and meals from MAD or its designee and document that the treatment is not available in New Mexico; follow specified authorization timeframes for lodging.
- Authorization for out-of-state lodging and meals can be granted for up to 30 calendar days and must be re-evaluated every 30 days.
- Out-of-state travel must be justified by documentation that the treatment is not available in-state.
Complete consent and retain records for pregnancy termination
Complete and file the required pregnancy termination consent that includes written certification of the allowed condition; give the recipient a dated and signed copy and retain the original in the medical record.
- Consent is valid for 30 calendar days from the date of signature unless withdrawn.
- Provider must certify in writing which allowed condition for termination applies and include required acknowledgements.
Document tobacco cessation counseling and prescriptions
For tobacco cessation counseling, maintain documentation to substantiate medical necessity and show that face-to-face counseling was prescribed by a practitioner; retain records consistent with other NMAC rules.
- Documentation may consist of documentation of tobacco use and evidence that face-to-face counseling was prescribed by a practitioner.
- There are no limits on quit attempts or counseling session counts per year.
Review UR instructions and program rules; provide requested documentation
Review utilization review instructions and program rules available from MAD or its designee and supply necessary information requested to obtain payment; verify medical necessity and eligibility before furnishing services.
- Providers must adhere to MAD program rules, UR instructions, and provider participation agreement provisions to be eligible for reimbursement.
- A provider must verify that MAD covers a specific service and that the service is medically necessary prior to furnishing the service.
Prepare for review — verify eligibility and medical necessity
Be prepared for pre-payment, concurrent, or post-payment review; ensure services are medically necessary and that provider enrollment/eligibility is documented at time services are furnished to avoid denial or recoupment.
- All claims are subject to pre-payment or post-payment review and recoupment.
- Providers must be enrolled and eligible at the time services are furnished; medical necessity determinations are made by MAD or its designee.
Risk of recoupment for transportation to non-covered services or missing CMT docs
Do not bill or seek transportation payment for travel to non-covered MAD services; CMT advances require timely documentation or MAD may initiate recoupment proceedings.
- Payment for transportation to a non-covered MAD service is subject to retroactive recoupment.
- If a MAP eligible recipient fails to provide supporting documentation for CMT advances, recoupment proceedings are initiated.
Anesthesia documentation must be retained or risk denial
Failure to document medical necessity for general anesthesia or IV sedation risks denial; maintain and make available supporting documentation for review by MAD or its designee.
- Documentation of medical necessity must be available for review for general anesthesia and intravenous sedation.
- Lack of documentation may result in denial of payment.
CMT advances subject to recoupment if supporting documentation not provided
Failure to provide required supporting documentation for CMT fund advances will result in recoupment proceedings; provide required referrals and receipts within specified timeframes.
- Advance funds are disbursed only after verification of eligibility and appointment; written referral for out-of-community service must be received no later than 30 calendar days from the date of appointment.
- If supporting documentation is not provided, recoupment proceedings are initiated.
Billing without required prior authorization risks denial/recoupment
Services billed without required prior authorization remain subject to utilization review and may be denied or recouped; verify prior authorization requirements before billing.
- A claim for a service that requires a prior authorization is paid only if the prior authorization is furnished.
- Services billed without required prior authorization remain subject to UR and potential denial or recoupment.
Noncovered or not medically necessary services can be denied and recouped
If a service is not a covered MAD benefit or is determined not medically necessary, payment will be denied and payments made may be recouped; maintain documentation to support medical necessity.
- If MAD determines a service was not performed, not a covered benefit, or not medically necessary, the payment is recouped.
- Retrospective reviews can lead to recoupment even after payment is made.
Prior authorization is not a guarantee of eligibility or payment
A prior authorization does not guarantee eligibility or final payment; verify recipient eligibility at the time services are furnished and understand approvals remain subject to later denial if medical necessity is not supported.
- A prior authorization does not guarantee that an individual is eligible for a specific MAD service.
- Approved services may still be denied later if determined not medically necessary or if the recipient was ineligible.
Policy background and scope
MAD reimburses medically necessary services furnished to MAP eligible recipients for diagnosis and treatment of illness, injury, or conditions, consistent with federal Medicaid regulations. Services must be provided by MAD-enrolled providers within their scope of practice and are subject to utilization review, prior authorization requirements where specified, and medical necessity determinations made by professional peers. This rule applies statewide to providers and recipients seeking to understand covered services, limitations, and administrative requirements under MAP.
Key definitions used in this policy
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