Current through Register Vol. 35, No. 18, September 24, 2024
A. A provider
who furnishes services to an eligible recipient must comply with all federal
and state laws, regulations, rules, and executive orders relevant to the
provision of services as specified in the MAD provider participation agreement
and the DOH provider agreement. A provider also must meet and adhere to all
applicable NMAC rules and instructions as specified in the MAD provider rules
manual and its appendices, DDW service standards, DDW service definitions, and
program directions and billing instructions, as updated. A provider is also
responsible for following coding manual guidelines and the centers for medicare
and medicaid services (CMS) correct coding initiatives, including not
improperly unbundling or upcoding services.
B. A provider must verify that an individual
is eligible for a specific health care program administered by the HSD and its
authorized agents and must verify the eligible recipient's enrollment status at
the time services are furnished. A provider must determine if an eligible
recipient has other health insurance. A provider must maintain records that are
sufficient to fully disclose the extent and nature of the services provided to
an eligible recipient.
C. Provider
agencies must mitigate any conflict of interest issues by adhering to at least
the following:
(1) Any individual who
operates or is an employee or subcontractor of a DDW provider shall not serve
as guardian for a person served by that agency, except when related by affinity
or consanguinity Paragraph (1) of Subsection A of Section
45-5-31 NMSA 1978. Affinity which
stems solely from the caregiver relationship is not sufficient to satisfy this
requirement.
(2) DDW provider
agencies may not employ or sub-contract with a direct support person who is an
immediate family member to support the person in services, except when the
person is in family living, respite, or customized in home supports
(CIHS).
(3) DDW provider agencies
may not employ or subcontract with the spouse of the participant to support the
person in any DDW funded services.
D. Case management agencies are required to
mitigate real or perceived conflict of interest issues by adhering to, at
minimum the following requirements. Case managers who are contracted under the
DDW are identified as agents who are responsible for the development of the
ISP.
(1) Case management agency owners and
individually employed or contracted case managers may not:
(a) be related by blood or affinity to the
person supported, or to any paid caregiver of the individual supported.
Following formal authorization from DDSD, a case manager may provide family
living services or respite to their own family member;
(b) have material financial interest in any
entity that is paid to provide DDW or mi via services. A material financial
interest is defined as anyone who has, directly or indirectly, any actual or
potential ownership, investment, or compensation arrangement;
(c) be empowered to make financial or health
related decisions for individuals on their caseload;
(d) be related by blood or affinity to any
DDW service provider for individuals on their caseload. Providers are
identified as providers of living care arrangements, community inclusion
services, mi via consultants, mi via vendors, BSC's and therapist.
(2) A case management provider
agency may not:
(a) be a provider agency for
any other DDW service;
(b) provide
guardianship services to an individual receiving case management services from
that same agency;
(3) A
case manager or director of a case management provider agency may not:
(a) serve on the board of directors of any
DDW provider agency;
(b) provide
training to staff of DDW provider agencies unless meeting criteria as outlined
in the DDW service standards.
(4) Case management provider agencies must
disclose to both DDSD and the people supported by their agency any familial
relationships between employees or subcontract case managers and providers of
other DDW services.
(5) Case
management provider agency staff and subcontractors must maintain independence
and avoid all activity which could be perceived as a potential conflict of
interest.
