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
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:
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: