N.M. Admin. Code § 8.324.7.11

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

Section 8.324.7.11 - PROVIDER RESPONSIBILITIES AND REQUIREMENTS

A. A provider who furnishes services to a MAP eligible recipient must comply with all federal, state, local laws, rules, regulations, executive orders and the provisions of the provider participation agreement (PPA). A provider must adhere to MAD program rules as specified in the New Mexico MAD administrative code (NMAC) rules, and policies that include but are not limited to supplements, billing instructions, and UR directions, as updated. The provider is responsible for following coding manual guidelines and centers for medicare and medicaid services (CMS) correct coding initiatives, including not improperly unbundling or upcoding services.

B. A provider must verify an individual is eligible for a specific MAD service and verify the recipient's enrollment status at time of service as well as determining if a copayment is applicable or if services require prior authorization. A provider must determine if a MAP eligible recipient has other health insurance. A provider must maintain records that are sufficient to fully disclose the extent and nature of the services provided to a MAP eligible recipient.

C. MAD services furnished must be within the scope of practice defined by the provider's licensing board, scope of practice act, or regulatory authority. See 8.302.1 NMAC.

N.M. Admin. Code § 8.324.7.11

8.324.7.11 NMAC - Rp, 8.324.7.11 NMAC, 1-1-14