N.M. Admin. Code § 8.312.2.25

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

Section 8.312.2.25 - REIMBURSEMENT

A NF provider must submit claims for reimbursement on the long term care turn around document (TAD) or its successor; see 8.302.2 NMAC.

A. MAD reimburses a NF at the lesser of the following:

(1) the NF's billed charges;

(2) the prospective reimbursement rates constrained by the ceilings established by MAD; see 8.312.3 NMAC; and

(3) the NF's billed charge must be its usual and customary charge for services; "usual and customary charge" refers to the amount which the individual provider charges the general public in the majority of cases for a specific procedure or service.

B.Reimbursement limitations: Payments are made only to a MAD enrolled, and as appropriate a HSD MCO contracted NF. Payments to a NF are limited to those service costs which are included as allowable costs under approved provisions of the medicaid state plan or the MAD alternative benefit; see 8.312.3 NMAC. All claims for payment from MAD or the MCO are subject to utilization review and control.

C.Reimbursement methodology: See 8.312.3 NMAC for a detailed description of this methodology.

N.M. Admin. Code § 8.312.2.25

8.312.2.25 NMAC - Rp, 8.312.2.25 NMAC, 8/1/14