Current through Register Vol. 35, No. 18, September 24, 2024
MAD covers outpatient services which are medically necessary
for prevention, diagnosis or rehabilitation as indicated by the condition of an
eligible recipient.
Services must be furnished within the scope and practice of a
professional provider as defined by state laws and regulations.
A. Outpatient covered services: Covered
hospital outpatient care includes the use of minor surgery or cast rooms,
intravenous infusions, catheter changes, first aid care of injuries, laboratory
and radiology services, and diagnostic and therapeutic radiation, including
radioactive isotopes. A partial hospitalization program in a general hospital
psychiatric unit is considered under outpatient services. See 8.321.5 NMAC,
Outpatient Psychiatric Services and Partial
Hospitalization.
B.
Outpatient noncovered services: MAD does not cover the following specific
outpatient benefits:
(1) outpatient hospital
services not considered medically necessary for the condition of the eligible
recipient;
(2) outpatient hospital
services that require prior approval for which the approval was not requested
except in cases with extenuating circumstances as granted by MAD or its
designee;
(3) outpatient hospital
services furnished to an individual who was not eligible for MAD services on
the date of service;
(4)
experimental or investigational procedures, technologies or therapies and the
services related to them, including hospitalization, anesthesiology, laboratory
tests, and imaging services; see 8.325.6 NMAC, Experimental or
Investigational Procedures or Therapies;
(5) drugs classified as "ineffective" by the
federal food and drug administration;
(6) laboratory specimen handling or mailing
charges; and
(7) formal educational
or vocational services which relate to traditional academic subjects or
training for employment.
C. MCO payment rates: If a provider and an
MCO are unable to agree to terms or fail to execute an agreement for any
reason, the MCO shall be obliged to pay, and the provider shall accept, one
hundred percent of the "applicable reimbursement rate" based on the provider
type for services rendered under both emergency and non-emergency situations.
The "applicable reimbursement rate" is defined as the rate paid by HCA to the
provider participating in medicaid or other medical assistance programs
administered by HCA and excludes disproportionate share hospital and medical
education payments.
D. Prior
authorization: Certain procedures or services performed in outpatient settings
can require prior approval from MAD or its designee. Outpatient physical,
occupational, and speech therapies services require prior
authorization.
E. Reimbursement for
outpatient services: Effective November 1, 2010, outpatient hospital services
are reimbursed using outpatient prospective payment system (OPPS) rates. The
OPPS rules for payment for packaged services, separately reimbursed services
are based on the medicare ambulatory payment classification (APC) methodology.
(1) Reimbursement for laboratory services,
radiology services, and drug items will not exceed maximum levels established
by MAD. Hospitals must identify drugs items purchased at 340B prices.
(2) Services or supplies furnished by a
provider under contract or through referral must meet the contract services
requirements and be reimbursed based on approved methods. See 8.302.2 NMAC,
Billing For Medicaid Services.
(3) For critical access hospital providers,
the MAD outpatient prospective payment system (OPPS) fee-for-service rate will
be set based on the provider's reported cost to charge ratio reported in the
provider's most recently filed cost report prior to February 1, 2012.
(4) For services not reimbursed using the
outpatient prospective payment system (OPPS) methodology or fee schedule,
reimbursement for a MAD fee-for-service provider will be made using the
medicare allowable cost method, reducing medicare allowable costs by three
percent. An interim rate of payment is established by MAD. A rate of payment
for providers not subject to the cost settlement process is also established by
MAD to equal or closely approximate the final payment rates that apply under
the cost settlement TEFRA principals. If the provider is not cost settled, the
reimbursement rate will be at the provider's cost to charge ratio reported in
the provider's most recently filed cost report prior to February 1, 2012.
Otherwise, rates are established after considering available cost to charge
ratios, payment levels made by other payers, and MAD payment levels for
services of similar cost, complexity and duration.
