N.M. Admin. Code § 8.314.3.16

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

Section 8.314.3.16 - Utilization Review

All medicaid services, including services covered under the MFW, are subject to utilization review for medical necessity and program compliance. Reviews can be performed before services are furnished, after services are furnished and before payment is made, or after payment is made. See Section 8.310.2.14 NMAC. Once enrolled, providers receive instructions and documentation forms necessary for prior approval and claims processing.

A.Prior approval: To be eligible for MFW program services, recipients must require an ICF/IID LOC and meet the eligibility requirements defined in Subsection B of Section 8.314.3.12 NMAC. LOC determinations are made by MAD or its designee. The ISP must specify the type, amount and duration of services. Certain procedures or services specified in the ISP can require prior approval from MAD or its designee. Services for which prior approval was obtained remain subject to utilization review at any point in the payment process.

B.Eligibility determination: Prior approval of services does not guarantee that individuals are eligible for MAP. Providers must verify that individuals are eligible for MAP at the time services are furnished and determine if recipients have other health insurance.

C.Reconsideration: Providers who disagree with prior approval request denials or other review decisions can request a re-review and reconsideration. See Section 8.350.2 NMAC.

N.M. Admin. Code § 8.314.3.16

2/1/95, 4/15/96; 8.314.3.16 NMAC - Rn, 8 NMAC 4.MAD.734.7, 5/1/02; A, 12/1/10, Adopted by New Mexico Register, Volume XXIX, Issue 04, February 27, 2018, eff. 3/1/2018