N.M. Admin. Code § 8.326.2.17

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

Section 8.326.2.17 - REIMBURSEMENT

A. Case management providers must submit claims for reimbursement on the HCFA-1500 claim form or its successor. See 8.302.2 NMAC, Billing for Medicaid Services. Instructions on documentation, billing and claims processing are sent to approved medicaid providers. Reimbursement for covered case management services is made at the lesser of the following:

(1) the provider's billed charge; or

(2) the MAD fee schedule for the specific service or procedure.

B. The provider's billed charge must be their usual and customary charge for an average month of services to individuals who are part of the target population. Monthly charges are based on a cost analysis conducted periodically by the HCA.

C. "Usual and customary charge" refers to the amount which the individual providers charge the general public in the majority of cases for a specific procedure or service.

D. For case management services furnished by an institution, costs associated with case management must be removed from their cost reports prior to cost settlement or rebasing.

N.M. Admin. Code § 8.326.2.17

2/1/95; Recompiled 11/30/01, Adopted by New Mexico Register, Volume XXXV, Issue 12, June 25, 2024, eff. 7/1/2024