New Mexico Administrative Code
Title 8 - SOCIAL SERVICES
Chapter 301 - MEDICAID GENERAL BENEFIT DESCRIPTION
Part 5 - MEDICAL MANAGEMENT
Section 8.301.5.11 - IDENTIFICATION OF CANDIDATES
Current through Register Vol. 35, No. 6, March 26, 2024
All Medicaid recipients are potential candidates for inclusion in Medical Management, whether enrolled in Salud! or covered under Medicaid fee-for-service. Recipients are identified as candidates for review by HSD, the MCO, a provider or other appropriate entities. The following situations may indicate a need for Medical Management:
A. Individuals who overutilize medical services;
B. Individuals who are habitually non-compliant and miss appointments, or who frequently seek unauthorized treatment or care; and
C. Individuals who frequently change PCPs or simultaneously utilize multiple pharmacy providers.
D. Individuals who regularly utilize emergency room services for inappropriate, non-emergency care.
