New Mexico Health Care Authority Coverage Criteria
- New Mexico Health Care Authority prior authorization
- New Mexico Health Care Authority timely filing
- All New Mexico Health Care Authority policy updates
Latest New Mexico Health Care Authority coverage criteria updates25
- Coverage CriteriaClinical/Medical PolicyEff. 2025-04-01Accredited Residential Treatment Centers (ARTC) and Adult Accredited Residential Treatment Centers (AARTC) — Coverage CriteriaStandards, provider eligibility, member eligibility, covered services, authorization, and billing rules for Accredited Residential Treatment Centers for Youth (ARTC) and Adult Accredited Residential Treatment Centers for Substance Use Disorder (AARTC) under New Mexico Medicaid.All New Mexico Health Care Authority updates
- Coverage CriteriaClinical/Medical PolicyEff. 2025-01-01Clinic Services (including Renal Dialysis Clinics) — Coverage CriteriaDefines New Mexico Medicaid coverage and limitations for clinic services under Section 1905(a)(9) of the Social Security Act, including specific provisions for renal dialysis clinics and IHS/Tribal clinics. Affects providers furnishing outpatient clinic services to New Mexico Medicaid beneficiaries.All New Mexico Health Care Authority updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-10-01Applied Behavior Analysis / Behavior Intervention Services (Stage 3 AI) coverage criteriaDefines Stage 3 AI (Applied Intervention) services, practitioner qualifications for behavior technicians (BTs), and lists behavior-change intervention techniques covered under the New Mexico Medicaid State Plan.All New Mexico Health Care Authority updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-10-01Orthodontic Medical Necessity CriteriaDefines medical necessity, documentation, provider eligibility, billing, and prior authorization requirements for orthodontic treatment for eligible New Mexico Medicaid members under age 21. Affects Turquoise Care MCOs and dental providers billing Medicaid.All New Mexico Health Care Authority updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-10-01Stage 2 Behavior Analytic Assessment and Autism Intervention Treatment Plan (AITP) Coverage CriteriaDefines practitioner requirements, assessment components, and service descriptions for Stage 2 Applied Intervention (AI) services for individuals with Autism Spectrum Disorder under New Mexico's Medicaid State Plan; affects behavior analysts and related providers seeking reimbursement for Stage 2 services.All New Mexico Health Care Authority updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-07-01Coverage Criteria for Prosthetic and Custom Orthotic DevicesDirects New Mexico MCOs on updated coverage and reimbursement for prosthetic and custom orthotic devices for Medicaid-eligible recipients, effective July 1, 2024.All New Mexico Health Care Authority updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-07-01Dental services — Orthodontics and Silver Diamine Fluoride (SDF) coverage criteriaGoverns Medicaid coverage, provider requirements, and medical necessity criteria for dental services (including orthodontics and silver diamine fluoride) for New Mexico Medicaid members, including EPSDT-eligible recipients and providers enrolled with New Mexico Medicaid.All New Mexico Health Care Authority updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-07-01Dental services — orthodontics and silver diamine fluoride (SDF) coverage criteriaGoverns coverage, provider eligibility, documentation, and medical necessity criteria for dental services in New Mexico Medicaid, including orthodontics for recipients under age 21 and use of silver diamine fluoride by dental and medical providers.All New Mexico Health Care Authority updates
- Coverage CriteriaClinical/Medical PolicyEff. 2024-07-01Section 20: Pharmacy — Turquoise Care Pharmacy Benefits (Coverage Criteria)Rules and requirements for Managed Care Organizations (MCOs) administering Turquoise Care pharmacy benefits, including formulary/PDL, MAT, HCV, HIV, diabetic supplies, community pharmacy reimbursement, 340B billing, and related operational obligations.All New Mexico Health Care Authority updates
- Coverage CriteriaClinical/Medical PolicyEff. 2023-07-01Community Health Worker (CHW) / Community Health Representative (CHR) preventive services coverage criteriaDefines New Mexico Medicaid coverage, scope, and payment approach for CHW/CHR services as a reimbursable preventive service under 42 CFR 440.60, effective July 1, 2023, for Medicaid beneficiaries in New Mexico.All New Mexico Health Care Authority updates
- Coverage CriteriaClinical/Medical PolicyEff. 2022-10-01Autism Intervention (AI) Services — Coverage Criteria (State Plan Attachment 3.1A)Defines coverage, practitioner requirements, evaluation and treatment stages (Stage 1–3) for Autism Intervention services for individuals diagnosed with or at risk for Autism Spectrum Disorder under New Mexico's Medicaid State Plan.All New Mexico Health Care Authority updates
- Coverage CriteriaAdministrative/Operational PolicyEff. 2022-01-01AGED, BLIND AND DISABLED — SSI Extensions, WDI, MSPs, and IC/Waiver Coverage CriteriaDefines income, resource, and program rules for SSI extensions (DAC, Widower, 503 Lead/Pickle), Working Disabled Individuals (WDI), Medicare Savings Programs (QMB, SLIMB, QI/Q1), IC/Waiver, and related coverage determinations for beneficiaries in New Mexico's aged, blind, and disabled Medicaid population.All New Mexico Health Care Authority updates
- Coverage CriteriaClinical/Medical PolicyEff. 2020-01-01Specialized Behavioral Health Services rule (8.321.2 NMAC)Replaces and updates New Mexico's Medicaid rule governing specialized behavioral health services including provider types, service definitions, coverage criteria, and new benefits for Centennial Care recipients.All New Mexico Health Care Authority updates
- Coverage CriteriaClinical/Medical PolicyEff. 2019-10-15Applied Behavior Analysis (ABA) coverage criteria — Section A. Coverage CriteriaComments and recommendations to New Mexico Health Care Authority about Section A Coverage Criteria for Specialized Behavioral Health Services, focusing on ABA benefit eligibility, provider roles, prior authorization, age limits, and diagnosis-specific restrictions. Affects state Medicaid behavioral health policy and providers delivering ABA services in New Mexico.All New Mexico Health Care Authority updates
- Coverage CriteriaClinical/Medical PolicyEff. 2019-01-01Medicaid Section 1115 SUD Demonstration — Implementation, Monitoring, and Milestone Evaluation (Coverage Criteria)Governs New Mexico's Medicaid Section 1115 substance use disorder (SUD) demonstration implementation, monitoring, and milestone evaluation for Medicaid enrollees with an SUD diagnosis during the demonstration period. Affects state Medicaid program, participating providers, MCOs, and enrolled beneficiaries.All New Mexico Health Care Authority updates
- Coverage CriteriaClinical/Medical PolicyEff. 2019-01-01Pharmacy (Centennial Care) — Coverage Criteria and HCV Treatment GuidanceDefines Centennial Care pharmacy benefit rules and Managed Care Organization (MCO) obligations for formulary management, prior authorization, Hepatitis C treatment guidance, community pharmacy reimbursement, DUR participation, drug rebate dispute resolution, and PBM oversight. Applies to MCOs administering New Mexico Centennial Care pharmacy services.All New Mexico Health Care Authority updates
- Coverage CriteriaAdministrative/Operational PolicyEff. 2019-01-01TITLE 8 SOCIAL SERVICES CHAPTER 299: Medicaid Eligibility - Family Planning Services Part 400 Recipient RequirementsState rule defining who is eligible for New Mexico Medicaid limited to family planning and related services, including general and income requirements; applies to the general public.All New Mexico Health Care Authority updates
- Coverage CriteriaClinical/Medical PolicyEff. 2018-03-01Medically Fragile Home and Community-Based Services Waiver - Coverage CriteriaState rule describing eligibility, provider qualifications, covered waiver services, provider responsibilities, and program structure for New Mexico's medically fragile HCBS waiver program for individuals with developmental disabilities and medically fragile conditions.All New Mexico Health Care Authority updates
- Coverage CriteriaClinical/Medical PolicyEff. 2016-03-01Developmental Disabilities Home and Community-Based Services Waiver (DDW) — Amendments to 8.314.5 NMAC (coverage criteria)Proposed amendments to New Mexico's 8.314.5 NMAC governing the DDW waiver: clarifies definitions, provider qualifications, service packages, clinical review, appeal processes, and documentation requirements for Medicaid-eligible recipients and participating providers.All New Mexico Health Care Authority updates
- Coverage CriteriaClinical/Medical PolicyEff. 2014-01-01Agency-Based Community Benefit (ABCB) — Coverage Criteria for Home and Community-Based ServicesStandards, 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.All New Mexico Health Care Authority updates
- Coverage CriteriaClinical/Medical PolicyEff. 2014-01-01EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT (EPSDT) SERVICESDefines Early and Periodic Screening, Diagnostic and Treatment (EPSDT) supplemental services for MAP-eligible recipients under 21 including special rehabilitation, case management, personal care services (PCS), and private duty nursing (PDN); describes provider eligibility, service definitions, coverage criteria, treatment plan and utilization controls.All New Mexico Health Care Authority updates
- Coverage CriteriaClinical/Medical PolicyApplied Behavior Analysis (ABA) services — Coverage Criteria and Prior AuthorizationPublic comments and recommendations regarding New Mexico Administrative Code 8.321.2 Specialized Behavioral Health Services focused on coverage, eligible providers, prior authorization, and age/diagnosis limits for ABA services; affects state behavioral health policy and provider reimbursement in New Mexico.All New Mexico Health Care Authority updates
- Coverage CriteriaClinical/Medical PolicyBehavior Management Services (BMS) - Coverage CriteriaDefines Medicaid-covered Behavior Management Services (BMS) for children and youth within New Mexico’s Medicaid program, describing purpose, basic elements, provider inputs, utilization trends, and future development considerations. Affects providers delivering behavioral management as part of comprehensive treatment for Medicaid-enrolled children and adolescents.All New Mexico Health Care Authority updates
- Coverage CriteriaClinical/Medical PolicyComments on NMAC 8.321.2 behavioral health provisions — coverage criteria & provider eligibilityPublic comments on NMAC 8.321.2 provisions for behavioral health services (crisis intervention, telephone crisis, supportive housing, therapeutic interventions) focusing on eligible provider definitions and supervision requirements; affects providers and policy drafters in New Mexico.All New Mexico Health Care Authority updates
- Coverage CriteriaClinical/Medical PolicyCommunity Benefit (Home and Community Based Services) — Coverage CriteriaDefines New Mexico Centennial Care's Community Benefit (CB) program — agency-based and self-directed HCBS models — eligibility, services, enrollment, and program responsibilities for members and managed care organizations.All New Mexico Health Care Authority updates
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Tool Description
Search New Mexico Health Care Authority coverage criteria and medical necessity requirements across 21,000+ policies from 170+ payers.
Search a drug (“Wegovy”), a procedure (“knee replacement”), or a policy name, then filter by payer, specialty, policy type, or effective year. Or start from the largest publishers: UnitedHealthcare coverage criteria and Cigna coverage criteria.
Each result links the full policy page, which lists the clinical requirements, covered codes, and effective dates from the source document.
Pair a criteria search with the prior authorization lookup for approval requirements, the timely filing lookup for claim deadlines, the live policy updates feed for the newest payer publications, and payer profiles for contacts and coverage context.
FAQ
Coverage criteria are the specific clinical requirements a payer sets for covering a drug, procedure, or service: diagnoses, symptom duration, prior treatments tried, age limits, and documentation. They are published inside medical policies and clinical criteria documents, and a claim or authorization that does not meet them is denied as not medically necessary.
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