Current through Register Vol. 35, No. 18, September 24, 2024
A. Health care to eligible recipients in a
health home is furnished by a variety of providers and provider groups. The
reimbursement and billing for these services is administered by medical
assistance division (MAD). Upon approval of a New Mexico provider participation
agreement (PPA) 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 agency must be enrolled before submitting a claim for payment to the
MAD claims processing contractors or the HCA contracted managed care
organizations (MCOs). MAD makes available on the HCA website, on other
program-specific websites, or in hard copy format, information necessary to
participate in health care programs administered by MAD or its designees
including program rules, billing instructions, utilization review (UR)
instructions, supplements, policy, and other pertinent materials. When
enrolled, a provider agency and a practitioner receive instruction on how to
access these documents. It is the provider agency's and practitioner's
responsibility to access these instructions, to understand the information
provided and to comply with the requirements. The provider agency must contact
HCA or its authorized agents to obtain answers to questions related to the
material. To be eligible for reimbursement, a provider agency and practitioner
must adhere to the provisions of the MAD PPA and all applicable statutes,
regulations, and executive orders. MAD, its selected claims processing
contractor or the MCO, issues payments to a provider agency using electronic
funds transfer (EFT) only. To be eligible to receive a CareLink NM health home
designation, a provider agency must hold a comprehensive community support
service (CCSS) certification or attest that the agency has received all
required training.
B. A provider
agency must follow CareLink NM staffing requirements found in this rule and
further detailed in the CareLink NM policy manual. The provider agency must
agree to fulfill other responsibilities as listed in Subsection B of
8.310.10.10 NMAC. The following
individuals and practitioners must be contracted or employed by the provider
agency as part of its CareLink NM service delivery:
(1) A director specifically assigned to
CareLink NM service oversight and administrative responsibilities.
(2) A health promotion coordinator with a
bachelor's-level degree in a human or health services field and experience in
developing curriculum and curriculum instruction. The health promotion
coordinator manages health promotion services and resources appropriate for an
eligible recipient such as interventions related to substance use prevention
and cessation, nutritional counseling, or health weight management;
(3) A care coordinator who develops and
oversees an eligible recipient's comprehensive care management, including the
planning and coordination of all physical, behavioral, and support services.
The number of care coordinators is based upon ratio in Paragraph (5) of
Subsection D of
8.310.10.11 NMAC. The care
coordinator:
(a) is a regulation and licensing
department (RLD) licensed behavioral health practitioner; or
(b) holds a bachelor's or master's level
degree and has two years of relevant healthcare experience; or
(c) is registered nurse in the state of New
Mexico; or
(d) is approved through
the CLNM NM health home steering committee.
(4) A community liaison who speaks a language
that is utilized by a majority of non-fluent English-speaking eligible
recipients, and who is experienced with the resources in the eligible
recipient's local community. The community liaison identifies, connects, and
engages with community services, resources, and providers. The community
liaison works with an eligible recipient's care coordinator in appropriately
connecting and integrating the eligible recipient to needed community services,
resources, and practitioners.
(5) A
supervisor who is an independently licensed behavioral health practitioner as
described in 8.321.2 NMAC who supervises the care coordinator, the community
liaison, the health promotion coordinator, peer and family support workers, and
other optional staff that is the part of the CareLink NM multidisciplinary
team. The supervisor must have direct service experience in working with both
adult and child populations. Physical health and psychiatric consultants must
comply with their respective licensing boards' requirements for
supervision.
(6) Certified peer
support worker(s) (CPSW) who hold a certification by the New Mexico
credentialing board for behavioral health professionals as a certified peer
support worker. The CPSW has successfully navigated their own behavioral health
experiences, and is willing to assist their peers in their recovery
processes.
(7) Certified family
support specialist(s) who hold a certification by the New Mexico credentialing
board for behavioral health professionals as a certified family support
worker.
(8) A physical health
consultant who is a physician licensed to practice medicine (MD) or osteopathy
(DO), a licensed certified nurse practitioner (CNP), or a licensed certified
nurse specialist (CNS) as described in 8.310.3 NMAC.
(9) A psychiatric consultant who is a
physician (MD or DO) licensed by the board of medical examiners or board of
osteopathy and is board-eligible or board-certified in psychiatry as described
in 8.321.2 NMAC.
