New Mexico Administrative Code
Title 8 - SOCIAL SERVICES
Chapter 310 - HEALTH CARE PROFESSIONAL SERVICES
Part 10 - HEALTH HOME SERVICES
Section 8.310.10.16 - PAYMENT FOR SERVICES AND BILLING INSTRUCTION
Current through Register Vol. 35, No. 18, September 24, 2024
CareLink NM services are reimbursed through a per-member-per-month (PMPM) payment to the provider agency. CareLink NM dedicated services are those outlined in 8.310.10.13 NMAC. MAD covered services provided to an eligible recipient including behavioral and physical health services, are billed and reimbursed independent of the PMPM payment to the provider agency. The PMPM reimbursement is paid for CareLink NM services regardless of whether the eligible recipient is a MCO member or enrolled in fee-for-service (FFS). The CareLink NM provider agency is responsible for verifying that the eligible recipient has affirmatively agreed to participate in CareLink NM services, documentation of which should be in a signed statement in the eligible recipient's file, in order to receive reimbursement. PMPM codes will be used to document various CareLink NM services provided to an eligible recipient, and trigger the PMPM reimbursement. To receive reimbursement, the provider agency must fully execute at least one CareLink NM service in a given month, meaning direct contact and interaction with an eligible recipient to deliver comprehensive care management, care coordination and health promotion, comprehensive transitional care, individual and family support services, or referral to community and support services. A non-exhaustive list of actions by a CareLink NM provider agency that fail to meet full execution of a CareLink NM service includes attempting to call or visit an eligible member. For referral to community and support services that may not include direct contact with an eligible recipient, the provider agency must, at a minimum, include a service referral and a follow-up with the service provider after the eligible recipient engagement, in order to receive reimbursement.
A. Fee-for-service (FFS) reimbursement: For an eligible recipient who is utilizing FFS benefits, the provider agency will submit a PMPM health home code through the fiscal agent's claims system when a CareLink NM service is provided to an eligible recipient, which will then result in a PMPM payment. The requirement for the provider agency to submit a claim for payment allows HCA to ensure that the eligible recipient receives the CareLink NM service before payment is made. If a CareLink NM service is not provided to an eligible recipient in a given month, the provider agency will not receive a PMPM payment. The claims submission also provides data to HCA on CareLink NM services rendered and the date of service for monitoring and evaluation purposes including outcome and quality studies.
B. Managed care reimbursement: For an eligible recipient who is a member of a MCO, the provider agency and the MCO shall negotiate reimbursement at an amount no less than the established PMPM rate for a health home.
