N.M. Admin. Code § 8.301.5.12

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

Section 8.301.5.12 - SELECTION FOR MEDICAL MANAGEMENT

HCA staff analyzes appropriate reports and documentation to decide whether a recipient will be referred to the MAD medical director for medical management determination. After reviewing HCA staff recommendations and supporting documentation, the MAD medical director or another physician designated by MAD determines whether the recipient should be assigned to medical management. Once the determination is made by the physician, the assignment of the recipient to medical management is implemented by MAD. The assignment is subject to the notice requirements and hearing process described below in Section 15, Recipient Notice and Section 16, Recipient Hearings.

A. Notification of decision: The HCA staff notifies the recipient, the claims processing contractor, the income support division (ISD), and, if enrolled in Salud!, the MCO, of the medical management assignments. Providers are informed that a client is in medical management at the time the provider verifies the client's eligibility for the date the services are provided. Recipients placed in medical management receive medicaid identification cards which indicate "medical management" and the names of their "designated providers".

B. Assignments for recipients covered by third party insurers: Recipients who are eligible for medicare and medicaid services or recipients who have insurance can be assigned to a designated provider for services covered exclusively by medicaid. Recipients in managed care plans are assigned to designated providers who participate in the recipient's plan.

N.M. Admin. Code § 8.301.5.12

2-1-95; 8.301.5.12 NMAC - Rn, 8 NMAC 4.MAD. 604.3 & A, 7-1-01, Adopted by New Mexico Register, Volume XXXV, Issue 12, June 25, 2024, eff. 7/1/2024