New Mexico Administrative Code
Title 8 - SOCIAL SERVICES
Chapter 320 - EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT) SERVICES
Part 6 - SCHOOL-BASED SERVICES FOR MAP ELIGIBLE RECIPIENTS UNDER TWENTY-ONE YEARS OF AGE
Section 8.320.6.12 - PROVIDER RESPONSIBILITIES
Universal Citation: 8 NM Admin Code 8.320.6.12
Current through Register Vol. 35, No. 18, September 24, 2024
A. General responsibilities:
(1) A
provider who furnishes services to an eligible recipient must comply with all
terms and conditions of his or her MAD PPA and the MAD New Mexico
administrative code (NMAC) rules.
(2) A provider must verify that an individual
is an eligible recipient at the time services are billed.
(3) A provider must appoint a program liaison
and backup alternate for each LEA, REC or other SFEA, who will be responsible
for receiving and disbursing all communication, information and guidelines from
HSD regarding the MAD school-based services program, including information on,
but not limited to, direct services and administrative claiming.
B. Documentation requirements:
(1) A provider must
maintain all records necessary to fully disclose the nature, quality, amount
and medical necessity of services billed to a MAP eligible recipient who is
currently receiving MAD services or has received MAD school-based services in
the past that are or were part of the eligible recipient's IEP, IFSP, 504 plan,
IHCP or other care plan. Payment for services billed to MAD that are not
substantiated in the eligible recipient's records are subject to recoupment.
Documentation must be retained for at least six years from the date of payment
or until ongoing audit issues are resolved, whichever is longer; see 8.302.2
NMAC.
(2) For services covered
under this rule, complete copies of the eligible recipient's IEP, IFSP, 504
plan, IHCP or other care plan with the individualized treatment plan (ITP)
portions of the IEP, IFSP, 504 plan, IHCP or other care plan must be maintained
as part of the required records. Those records must clearly indicate that the
MAD school-based service is a part of the eligible recipient's IEP, IFSP, 504
plan, IHCP or other care plan.
(3)
Documents in the MAP eligible recipient's file must include:
(a) the IEP, IFSP, 504 plan, IHCP or other
care plan with the ITP;
(b)
evaluation performed by the provider or the annual and current present level of
performance or other determination of medical necessity;
(c) annual PCP notification or documentation
of a good faith effort for services provided through an IEP/IFSP;
(d) treatment notes that relate directly to
the IEP, IFSP, 504 plan, IHCP or other care plan goals and objectives specific
to each MAP eligible recipient; and
(e) billing information recorded in units of
time; see 8.302.2 NMAC.
C. Record availability: The provider must upon request promptly furnish to HSD, the secretary of the federal department of health and human services, or the state medicaid fraud control unit any information required in this rule, including the eligible recipient and employee records, and any information regarding payments claimed by the provider furnishing services. Failure to provide records on request may result in a denial of claims.
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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