N.M. Admin. Code § 8.200.430.16

Current through Register Vol. 35, No. 23, December 10, 2024

Section 8.200.430.16 - [Effective 11/1/2024] ELIGIBLE RECIPIENT FINANCIAL RESPONSIBILITIES

A. A MAD provider agrees to accept the amount paid as payment in full. A provider cannot bill an eligible recipient for any unpaid portion of the bill (balance billing) or for a claim that is not paid because of a provider administrative error or failure of multiple providers to communicate eligibility information.

(1) An eligible recipient is responsible for any financial liability incurred if they fail to furnish current MAP eligibility identification before the receipt of a MAP service and as a result the provider fails to adhere to MAD reimbursement rules, such as a failure to request prior approval. If this omission occurs, the settlement of claims for services is between the eligible recipient and the MAP provider. An individual is financially responsible for services received if they were not eligible for MAD services on the date services are furnished.

(2) When a provider bills MAD and the claim is denied, the provider cannot bill the eligible recipient. Exceptions exist for denials caused by MAP ineligibility or by an eligible recipient's failure to furnish MAP identification at the time of service.

(3) If an eligible recipient fails to notify a provider that they have received services that are limited by time or amount, the eligible recipient is responsible to pay for services if, before furnishing the services, the provider makes reasonable efforts to verify whether the eligible recipient has already received services.

B. Failure of an eligible recipient to follow their privately held health insurance carrier's requirements: An eligible recipient must be aware of the physician, pharmacy, hospital, and other providers who participate in their HMO or other managed care plan. An eligible recipient is responsible for payment for services if they use a provider who is not a participant in their plan or if they receive any services without complying with the rules, policies, and procedures of their plan.

C. Other eligible recipient payment responsibilities: If all the following conditions are met before a MAD service is furnished, the eligible recipient can be billed directly by a MAD provider for services and is liable for payment:

(1) the eligible recipient is advised by a provider that the particular service is not covered by MAD or is advised by a provider that they are not a MAD provider;

(2) the eligible recipient is informed by a provider of the necessity, options, and charges for the services and the option of going to another provider who is a MAD provider; and

(3) the eligible recipient agrees in writing to have the service provided with full knowledge that they are financially responsible for the payment.

N.M. Admin. Code § 8.200.430.16

8.200.430.16 NMAC - Rp, 8.200.430.16 NMAC, 1-1-14, Amended by New Mexico Register, Volume XXV, Issue 19, October 15, 2014, eff. 10/15/2014, Amended by New Mexico Register, Volume XXVIII, Issue 18, September 26, 2017, eff. 10/1/2017, Amended by New Mexico Register, Volume XXXI, Issue 02, January 28, 2020, eff. 2/1/2020, Amended by New Mexico Register, Volume XXXV, Issue 20, October 22, 2024, eff. 11/1/2024