New Mexico Administrative Code
Title 8 - SOCIAL SERVICES
Chapter 300 - MEDICAID GENERAL INFORMATION
Part 22 - ELECTRONIC HEALTH RECORDS INCENTIVE PROGRAM
Section 8.300.22.10 - ELIGIBLE PROVIDERS

Universal Citation: 8 NM Admin Code 8.300.22.10

Current through Register Vol. 35, No. 18, September 24, 2024

A. Health care to New Mexico MAD eligible recipients is furnished by a variety of providers and provider groups. The reimbursement for these services is administered by MAD. Upon approval of a New Mexico MAD provider participation agreement or a MAD EHR incentive payment agreement by MAD or its designee, licensed practitioners, facilities and other providers of services that meet applicable requirements are eligible to be reimbursed for furnishing covered services to eligible recipients. A provider must be approved before submitting a claim for payment to the MAD claims processing contractors. MAD makes available on the HSD/MAD website, on other program-specific websites, or in hard copy format, information necessary to participate in health care programs administered by HSD or its authorized agents, including program rules, billing instructions, utilization review instructions, and other pertinent materials. When approved, a provider receives instruction on how to access these documents. It is the provider's responsibility to access these instructions, to understand the information provided and to comply with the requirements. The provider must contact HSD or its authorized agents to obtain answers to questions related to the material or not covered by the material. To be eligible for reimbursement, a provider must adhere to the provisions of the MAD provider participation agreement or a MAD EHR incentive payment agreement, and all applicable statutes, regulations, and executive orders. MAD or its selected claims processing contractor issues payments to a provider using electronic funds transfer (EFT) only.

B. To qualify for incentive payments, a provider must be an eligible professional or an eligible hospital. A provider who receives incentive payments must have an existing fee-for-service (FFS) MAD provider participation agreement or a MAD EHR incentive payment agreement, and at least one of their facilities must be located within the state of New Mexico.

(1) An eligible professional provider may not be hospital-based, unless they practice predominantly at a federally qualified health center (FQHC) or a rural health center (RHC) as defined by the CMS final rule. A professional provider is considered "hospital-based" if he/she furnishes 90 percent or more of his/her medicaid professional services during the relevant EHR reporting period in a hospital inpatient or emergency room, using the facilities and equipment of the hospital. An eligible professional provider may not participate in both the medicaid EHR incentive payment program and medicare EHR incentive payment program during the same payment year. Eligible professional providers include:
(a) a physician;

(b) a physician assistant practicing in a FQHC or RHC led by a physician assistant;

(c) a board certified pediatrician;

(d) a nurse practitioner;

(e) a certified nurse midwife;

(f) a dentist; or

(g) other type of provider when specifically allowed by CMS.

(2) Eligible hospitals are children's hospitals or acute care hospitals, including critical access hospitals and cancer hospitals. A hospital must meet either of the following definitions to be eligible for incentive payments:
(a) an acute care hospital is defined as a health care facility where the average length of patient stay is 25 days or fewer and that has a CMS certification number that has the last four digits in the series 0001-0879 and 1300-1399; or

(b) a children's hospital is defined as a separately certified children's hospital, either freestanding or hospital-within-hospital, that predominantly treats individuals under 21 years of age and has a CMS certification number with the last four digits in the series 3300-3399.

Disclaimer: These regulations may not be the most recent version. New Mexico may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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