New Mexico Administrative Code
Title 8 - SOCIAL SERVICES
Chapter 302 - MEDICAID GENERAL PROVIDER POLICIES
Part 1 - GENERAL PROVIDER POLICIES
Section 8.302.1.7 - DEFINITIONS
Universal Citation: 8 NM Admin Code 8.302.1.7
Current through Register Vol. 35, No. 18, September 24, 2024
Medically necessary services
A. Medically necessary services are clinical and rehabilitative physical or behavioral health services that:
(1) are essential to prevent, diagnose or
treat medical conditions or are essential to enable an eligible recipient to
attain, maintain or regain functional capacity;
(2) are delivered in the amount, duration,
scope and setting that is clinically appropriate to the specific physical and
behavioral health care needs of the eligible recipient;
(3) are provided within professionally
accepted standards of practice and national guidelines; and
(4) are required to meet the physical and
behavioral health needs of the eligible recipient and are not primarily for the
convenience of the eligible recipient, the provider or the payer.
B. Application of the definition:
(1) A determination that a service is
medically necessary does not mean that the service is a covered benefit or an
amendment, modification or expansion of a covered benefit, such a determination
will be made by MAD or its designee.
(2) The HCA or its authorized agent making
the determination of the medical necessity of clinical, rehabilitative and
supportive services consistent with the specific program's benefit package
applicable to an eligible recipient shall do so by:
(a) evaluating the eligible recipient's
physical and behavioral health information provided by qualified professionals
who have personally evaluated the eligible recipient within their scope of
practice, who have taken into consideration the eligible recipient's clinical
history including the impact of previous treatment and service interventions
and who have consulted with other qualified health care professionals with
applicable specialty training, as appropriate;
(b) considering the views and choices of the
eligible recipient or their personal representative regarding the proposed
covered service as provided by the clinician or through independent
verification of those views; and
(c) considering the services being provided
concurrently by other service delivery systems.
(3) Physical and behavioral health services
shall not be denied solely because the eligible recipient has a poor prognosis.
Required services may not be arbitrarily denied or reduced in amount, duration
or scope to an otherwise eligible recipient solely because of the diagnosis,
type of illness or condition.
(4)
Decisions regarding MAD benefit coverage for eligible recipients under 21 years
of age shall be governed by the early periodic screening, diagnosis and
treatment (EPSDT) coverage rules.
(5) Medically necessary service requirements
apply to all medical assistance program rules.
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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