N.M. Admin. Code § 8.325.10.16

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

Section 8.325.10.16 - UTILIZATION REVIEW

Claims for services to a recipient who is a non-citizen are reviewed by MAD or its designee before payment to determine if the circumstances warrant coverage.

A. Eligibility determination: A non-citizen recipient who requests MAD coverage for services must meet specific categorical eligibility requirements. Eligibility determinations by local county ISD offices must be made before the review for medical necessity.

B. Reconsideration: A provider and the non-citizen are given notice of the denial when the EMSA emergency criteria are not met. A non-citizen recipient can request a re-review and reconsideration of denied coverage of the service. See 8.350.2 NMAC, Reconsideration of Utilization Review Decisions. A non-citizen recipient can also request a hearing. See 8.52.2 NMAC, Recipient Hearings.

N.M. Admin. Code § 8.325.10.16

2/1/95; 8.325.10.16 NMAC - Rn, 8 NMAC 4.MAD.769.7 & A, 12/1/03; A, 10/15/08; A, 11/15/10, Amended by New Mexico Register, Volume XXXI, Issue 08, April 21, 2020, eff. 5/1/2020, Amended by New Mexico Register, Volume XXXII, Issue 24, December 28, 2021, eff. 1/1/2022, Adopted by New Mexico Register, Volume XXXV, Issue 12, June 25, 2024, eff. 7/1/2024