CurrentNew Mexico Health Care AuthorityPolicy 8.302.2

Billing for Medicaid Services (Part 2) — Provider Enrollment, Billing, Filing Limits, and Payment Rules

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Rules governing provider enrollment, billing, filing limits, payments (EFT), co-payments, billing responsibilities, and billing for dual-eligible recipients under the New Mexico Medical Assistance Programs (MAD). Applies to providers furnishing services to MAP eligible recipients and MCO members.

Policy Summary

PayerNew Mexico Health Care Authority

PolicyBilling for Medicaid Services (Part 2) — Billing and payment rules for MAD

Policy CodePolicy 8.302.2

Change TypeNo material change

Effective DateOct 1, 2017

Last ReviewJan 1, 2019

Next Review Date

Key ActionProviders must be enrolled and have an approved MAD provider participation agreement (PPA) before submitting claims and must follow MAD billing instructions.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

90 daysStandard filing limit

210 daysExtended filing limit (primary payer)

EFT onlyPayment method

8 minutes

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CurrentNew Mexico Health Care AuthorityPolicy 8.302.2

Billing for Medicaid Services (Part 2) — Provider Enrollment, Billing, Filing Limits, and Payment Rules

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Policy Summary

PayerNew Mexico Health Care Authority

PolicyBilling for Medicaid Services (Part 2) — Billing and payment rules for MAD

Policy CodePolicy 8.302.2

Change TypeNo material change

Effective DateOct 1, 2017

Last ReviewJan 1, 2019

Next Review Date

Key ActionProviders must be enrolled and have an approved MAD provider participation agreement (PPA) before submitting claims and must follow MAD billing instructions.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

90 daysStandard filing limit

210 daysExtended filing limit (primary payer)

EFT onlyPayment method

8 minutes

Min billable timed unit

1-time 90-dayResubmit grace

No reimbursementNo discharge-day pay

Billing and Payment Coverage Criteria

inv-01: Billing and payment criteria

Conditions and limitations on when MAD will reimburse and when providers may bill recipients:

Provider enrollment and participation agreement required before submitting claims

Provider must be enrolled and have an approved MAD provider participation agreement (PPA) and adhere to PPA, statutes, regulations, billing instructions, service standards, and UR instructions.

MAD issues payment only to provider or specified entities and uses electronic funds transfer (EFT) only

MAD payments are made to the provider or, in limited circumstances, to government agencies or business agents as specified; payments are issued via EFT only.

Providers must follow claim filing limits

Providers must meet MAD filing limits (standard limits described in policy) and are responsible for timely submission or for obtaining approved filing limit waivers when applicable.

Providers cannot bill recipients for denials caused by provider error or timely-filing failures when provider was informed of eligibility prior to service

If provider was informed of MAP eligibility or pending eligibility prior to rendering a benefit, the provider cannot bill the recipient for a denied claim except when denial is due to recipient ineligibility for that MAP category or the item is not a MAD benefit; in the latter case the provider must obtain prior signed acknowledgment.

Provider must accept MAD payment as payment in full except for allowed copayments/coinsurance/deductible

Providers must not bill remaining balance to recipient beyond MAD-allowed copayment, coinsurance or deductible.

ALL of the following

Bill appropriate Medicare payer first
Medicare pays covered portion first; MAD may pay remaining coinsurance/ deductible subject to MAD limits.
If claim does not auto-crossover, provider must submit Medicare payment and EOB to MAD and meet MAD filing limits
Provider must accept Medicare assignment for MAD eligible recipients; if provider does not participate in Medicare or accept assignment they must inform recipient and obtain consent before billing

ref": "b0_0

title": "inv-01: Billing and payment criteria"

ref": "b0_0

inv-02: MAD billing and payment limitations

MAD payment and billing limitations, and conditions under which contracted services may be billed through a participating provider.

ALL of the following

Allowed contracted billing scenarios
- Providers reimbursed at encounter/all-inclusive rates may include contracted services
- Practitioner groups, clinics, institutional professional components may bill for services furnished by contracted practitioners when provider applications are approved and rendering practitioner is listed on the claim
  MAD provider participation applications must be completed by billing entity and practitioner; practitioner must be listed as rendering provider.
- Transportation providers may bill for contracted personnel, equipment, or vehicles
- Billing allowed for contracted construction/assembly of prosthetics, dental devices, hearing/vision prosthesis, orthotics, and repairs when contractor not eligible provider and work is customary

Coding and Billing Rules

Timed service coding rulesmixedCovered

CPT/HCPCS timed codes

Units associated with time must follow CPT/HCPCS instructions; only direct patient time counts; total billed units limited to total treatment time.

Contracted practitioner billingmixedCovered

(see policy text)

A practitioner group, clinic, institutional professional component or providers of professional services may bill for services furnished by practitioners under contract when MAD provider participation applications are completed by the billing entity and the practitioner rendering the service (or in their employ).

Timed billing granularity — billing increments and minimum unit

Billing incrementsUnits billed per published chart: 8–22 min = 1 unit (.25 for second column), 23–37 = 2 units (.5), 38–52 = 3 units (.75), 53–67 = 4 units (1), 68–82 = 5 units (1.25), 83–97 = 6 units (1.5)

Minimum billable timeServices entirely less than 8 minutes cannot be billed

Timed units basisUnits are derived from total service minutes according to the 15-minute / per-hour chart ranges shown

Interest accrual period

Interest accrual periodInterest accrues for each 30-calendar-day period from the date of final determination

Start of accrual

Provider Responsibilities and Required Actions

Documentation Required

Enroll and follow MAD provider instructions before billing

Providers must be enrolled and have an approved MAD provider participation agreement (PPA) before submitting claims. MAD makes program rules, billing instructions, service standards, utilization review instructions and other pertinent material available (website or hard copy); when enrolled, providers receive instruction on how to access these documents and are responsible for accessing, understanding, and complying with them. MAD issues payments to providers via electronic funds transfer (EFT) only; providers must supply necessary information for payment.

Enroll and obtain an approved MAD PPA prior to submitting any claims.
Access and follow MAD program rules, billing instructions, service standards, and UR instructions as provided by MAD.
Provide necessary information to enable EFT payments.

Definitions

Authorized representative

DefinitionAn authorized representative is the individual designated to represent and act on behalf of the eligible recipient or member

Documentation requiredThe member or authorized representative must provide formal documentation authorizing the named individual(s) to access case information for a specified purpose and time frame

ExamplesMay be an attorney, person under power of attorney, guardian, or any individual designated in writing by the eligible recipient or member

Eligible recipient (FFS)

DefinitionAn eligible recipient is an individual who has met a MAP category of eligibility and receives MAD services through the fee-for-service (FFS) program

ProgramApplies specifically to recipients served under the MAD FFS program

Policy Summary

PayerNew Mexico Health Care Authority

PolicyBilling for Medicaid Services (Part 2) — Billing and payment rules for MAD

Policy CodePolicy 8.302.2

Change TypeNo material change

Effective DateOct 1, 2017

Last ReviewJan 1, 2019

Next Review Date

Key ActionProviders must be enrolled and have an approved MAD provider participation agreement (PPA) before submitting claims and must follow MAD billing instructions.

SourceLink

On This Page

All other contracted services require written prior approval from MAD or its designee before provision

Billing rates and reimbursement for contracted services

All services provided by a contractor and billed through a participating MAD provider must be billed at a rate based on direct and indirect costs plus a reasonable administrative charge; reimbursement for contracted services is included in the fee paid to the provider.

Providers cannot contract to restrict recipient freedom of choice except where permitted

Some restrictions may apply for purchases of medical devices, lab/radiology tests, transportation, or providers under an enrollment moratorium as identified by HHS/CMS.

Provider cannot bill dually eligible member for services Medicare/HMO cannot pay due to provider nonparticipation or non-acceptance of assignment without member's expressed consent

When crossover fails provider must submit Medicare payment and EOB and meet MAD filing limits; when payer payment exceeds MAD allowed amount claim considered paid in full and provider may not collect remaining portion from member; behavioral health psych reduction handled to allow provider up to 80% of payer allowed amount.

Payment not allowed to factors; no reimbursement for services on day of discharge; no payment for wrong patient/body part/procedure; MAD may deny/limit payment for acquired conditions

Interest on cost settlements

MAD charges interest on overpayments and pays interest on underpayments from date of final determination; interest accrues in 30-calendar-day periods; waivers may apply when overpayment liquidated within 30 days or administrative collection cost exceeds interest.

From date of final determination of costs or date required by subsequent administrative reversal

ApplicationInterest charged on overpayments and paid on underpayments resulting from cost settlements (waivers may apply)

Billing Rule

Collect managed care co-payments per 8.308.14 NMAC

MAD requires co-payments for specified medicaid managed care services; providers must follow the medicaid managed care co-payment rules, amounts, exemptions, provider responsibilities, and member rights detailed at 8.308.14 NMAC.

Charge only those co-payments and follow the exemptions and procedures listed in 8.308.14 NMAC.
Follow program guidance on provider responsibilities and member rights regarding co-payments.

Prior Authorization

Obtain written prior approval for non-specified contracted services

For contracted services not specifically allowed in MAD rules, obtain written prior approval from MAD or its designee before providing the services.

Do not furnish or bill for contracted services that lack specific allowance without prior written approval.
Ensure MAD-approved provider participation applications are completed where billing for contracted practitioners is permitted.

Billing Rule

Submit Medicare EOBs on non‑crossover claims and obtain member consent before billing

When claims do not auto-crossover from Medicare, providers must submit the Medicare payment and Medicare explanation of benefits (EOB) to the MAD claims processing contractor and meet MAD filing limits. Providers may not bill a dually eligible recipient or member for services Medicare will not pay due to the provider's nonparticipation, or for services MAD will not pay due to non-acceptance of assignment, without the recipient's/member's expressed consent; when a Medicare replacement/HMO payer amount exceeds MAD allowed, the claim is considered paid in full and the provider may not collect the remaining portion from the recipient/member.

If crossover fails, submit Medicare payment and EOB to MAD and comply with MAD filing deadlines.
Obtain expressed consent from the eligible recipient, member, or authorized representative before billing them for amounts resulting from provider Medicare nonparticipation or refusal to accept assignment.
Do not collect remaining co-payment/coinsurance/deductible from the recipient/member when a payer's payment exceeds the MAD allowed amount—the claim is paid in full.

ImplicationEligibility determines billing and filing rules applicable to FFS claims

Member (MCO)

DefinitionMember means a MAP eligible recipient who receives MAD services through a HSD-contracted managed care organization (MCO)

DistinctionMembers receive services via contracted MCOs rather than FFS MAD claims processing

RelevanceDifferent billing and copayment rules may apply to members versus FFS eligible recipients

Co-payment

DefinitionCo-payment is a fixed dollar amount a Medicaid recipient must pay directly to a provider for a service, visit, or item

TimingA co-payment is to be charged at the time of service or receipt of the item

ApplicabilityCo-payments are imposed according to MAD rules and the amounts/rules for managed care are specified in 8.308.14 NMAC

Claim crossover

DefinitionClaim crossover occurs when Medicare sends payment information directly to the MAD claims processing contractor in a 'cross-over claim' if sufficient information exists to identify the individual

Provider action when no crossoverIf claims fail to crossover automatically, the provider must bill the MAD claims processing contractor directly and supply the Medicare payment and EOB information

Filing limit requirementProviders must still meet MAD filing limits when submitting crossover or non-crossover claims

Factor — payment to collection/third-party agents

DefinitionA factor is an individual or organization (e.g., collection agency or service bureau) that may collect payments

MAD payment policyMAD does not pay factors either directly or by power of attorney (per 42 CFR 447.10(h))

ImplicationProviders cannot receive MAD payment routed through a factor; payments must be made to the provider per MAD rules