N.M. Admin. Code § 8.326.5.17

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

Section 8.326.5.17 - 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 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.

B. The provider's billed charge must be their usual and customary charge for services.

C. "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.

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

N.M. Admin. Code § 8.326.5.17

2/1/95; 10/15/96; 8.326.5.17 NMAC - Rn, 8 NMAC 4.MAD.774.8, 3/1/12