New Mexico Administrative Code
Title 8 - SOCIAL SERVICES
Chapter 301 - MEDICAID GENERAL BENEFIT DESCRIPTION
Part 5 - MEDICAL MANAGEMENT
Section 8.301.5.13 - DESIGNATED PROVIDERS

Universal Citation: 8 NM Admin Code 8.301.5.13

Current through Register Vol. 35, No. 6, March 26, 2024

Recipients who are in Medical Management are assigned to designated providers based on their specific health care situation. Recipients maybe assigned to a designated provider who manages the recipient's overall receipt of health services by making referrals, a designated provider who furnishes only specialty services, or both. Medicaid payment for medical services is restricted to designated providers. Other providers can receive payment for services furnished to a recipient in Medical Management only with a referral from the designated provider. If a recipient is assigned a designated psychiatrist, only that psychiatrist is reimbursed by Medicaid or the MCO for providing outpatient psychiatric services to the recipient, unless the designated psychiatrist determines that it is medically necessary for the recipient to be referred to a second psychiatrist. If a recipient is assigned a designated general provider, only that provider is reimbursed by Medicaid or the MCO for providing outpatient services to the recipient, unless the designated general provider determines that it is medically necessary for the recipient to be referred to a secondary provider. If a recipient isassigned a designated pharmacy provider, only that provider is reimbursed by Medicaid fee-for-service or the MCO.

A. Selection of Designated Providers: Providers of outpatient services are selected as "designated providers". The following guidelines are used to select a provider:

(1) The provider must be a Medicaid fee-for-service or MCO contracted provider;

(2) The provider agrees to act in the capacity of a designated provider;

(3) The geographic location of the provider must not significantly impair or impede the recipient's access to services; and

(4) When feasible, the provider is one with whom the recipient has previously established a medically-beneficial relationship.

(5) If the designated provider is not the recipient's PCP, then the provider must coordinate with the recipient's PCP.

B. Changing Designated Providers: When any of the following circumstances occur, the MAD Medical Director or another physician designated by MAD can approve a request to change the designated providers permanently:

(1) The recipient moves from the geographic area of the designated provider;

(2) The recipient's medical condition changes and the designated provider is unable to furnish care or refer the recipient to an appropriate provider;

(3) The designated provider is no longer available or gives notice that he is no longer willing to serve as a designated provider; or

(4) The designated provider no longer participates in the Medicaid program.

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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