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 8.320.6.17 - REIMBURSEMENT
Current through Register Vol. 35, No. 6, March 26, 2024
Reimbursement to the LEA, REC, or SFEA is not contingent upon billing a third party payer first when the eligible recipient has other insurance. MAD is generally the payer of last resort. However, if medical services are included in the eligible recipient's IEP, IFSP, 504 plan, IHCP or other care plan, and an exception is created under 42 USE 1396b(c), 20 USC 1412(a)(12) and 34 CFR 300.142., and the services are otherwise covered by MAD, then MAD is authorized to pay for such services. The LEA, REC, or other SFEA must submit claims for reimbursement on the 837P electronic format or its successor unless it received written permission from MAD to bill on paper.
A. Interim payment to the LEA, REC or other SFEA for covered services are made at the MAD fee schedule for the specific service.
B. The LEA, REC or other SFEA will complete an annual cost report utilized to reconcile interim payments with actual costs in accordance with CMS approved methodology. The LEA, REC or other SFEA must participate in the CMS approved quarterly random moment time study (RMTS).
C. A MAD school-based service that is in the eligible recipient's IEP, IFSP, 504 plan, IHCP or other care plan must only be billed by the school. When the school utilizes a contractor to render the service, the school must submit the claim, not the contractor. It is the responsibility of the school to reimburse the contractor.
