Current through Register Vol. 35, No. 18, September 24, 2024
A. Health care to New Mexico eligible
recipients is furnished by a variety of providers and provider groups. The
reimbursement for these services is administered by the HSD medical assistance
division (MAD). Upon approval of a New Mexico MAD provider participation
agreement (PPA) a licensed practitioner, a facility or other providers of
services that meet applicable requirements are eligible to be reimbursed for
furnishing MAD covered services to an eligible recipient. A provider must be
approved before submitting a claim for payment to the MAD claims processing
contractors. Information necessary to participate in health care programs
administered by HSD or its authorized agents, including New Mexico
administrative code (NMAC) program rules, program policy manuals, billing
instructions, supplements, utilization review (UR) instructions, and other
pertinent materials is available on the HSD website, on other program specific
websites or in hard copy format. When approved, a provider receives
instructions on how to access these documents. It is the provider's
responsibility to access these instructions, to understand the information
provided and to comply with the requirements. The provider must contact HSD or
its authorized agents to obtain answers to questions related to the material or
not covered by the material. To be eligible for reimbursement, providers and
practitioners must adhere to the provisions of his or her MAD PPA and all
applicable statutes, regulations, rules, and executive orders. MAD or its
selected claims processing contractor issues payment to a provider using the
electronic funds transfer (EFT) only. Providers must supply necessary
information as outlined in the PPA for payment to be made.
B. Services must be provided within the
licensure for each facility and scope of practice for each provider and
supervising or rendering practitioner. Services must be in compliance with the
statutes, rules and regulations of the applicable practice act. Providers must
be eligible for reimbursement as described in 8.310.2 NMAC and 8.310.3
NMAC.
C. The following independent
providers with active licenses (not provisional or temporary) are eligible to
be reimbursed directly for providing MAD behavioral health professional
services unless otherwise restricted or limited by NMAC rules:
(1) a physician licensed by the board of
medical examiners or board of osteopathy who is board eligible or board
certified in psychiatry, to include the groups they form;
(2) a psychologist (Ph.D., Psy.D. or Ed.D.)
licensed as a clinical psychologist by the New Mexico regulation and licensing
department's (RLD) board of psychologist examiners, to include the groups they
form;
(3) a licensed independent
social worker (LISW) or a licensed clinical social worker (LCSW) licensed by
RLD's board of social work examiners, to include the groups they
form;
(4) a licensed professional
clinical counselor (LPCC) licensed by RLD's counseling and therapy practice
board, to include the groups they form;
(5) a licensed marriage and family therapist
(LMFT) licensed by RLD's counseling and therapy practice board, to include the
groups they form;
(6) a licensed
alcohol and drug abuse counselor (LADAC) licensed by RLD's counseling and
therapy practice board or a certified alcohol and drug abuse counselor (CADC)
certified by the New Mexico credentialing board for behavioral health
professionals (CBBHP). Independent practice is for alcohol and drug abuse
diagnoses only. The LADAC or CADC may provide therapeutic services that may
include treatment of clients with co-occurring disorders or dual diagnoses in
an integrated behavioral health setting in which an interdisciplinary team has
developed an interdisciplinary treatment plan that is co-authorized by an
independently licensed counselor or therapist. The treatment of a mental health
disorder must be supervised by an independently licensed counselor or
therapist; or
(7) a clinical nurse
specialist (CNS) or a certified nurse practitioner (CNP) licensed by the New
Mexico board of nursing and certified in psychiatric nursing by a national
nursing organization, to include the groups they form, who can furnish services
to adults or children as his or her certification permits; or
(8) a licensed professional art therapist
(LPAT) licensed by RLD's counseling and therapy practice board, and certified
for independent practice by the art therapy credentials board (ATCB);
or
(9) an out-of-state provider
rendering a service from out-of-state must meet his or her state's licensing
and certification requirements which are acceptable when deemed by MAD to be
substantially equivalent to the license.
D. The following agencies are eligible to be
reimbursed for providing behavioral health professional services when all
conditions for providing services are met:
(1)
a community mental health center (CMHC);
(2) a federally qualified health center
(FQHC);
(3) an Indian health
service (IHS) hospital, clinic or FQHC;
(4) a PL 93-638 tribally operated hospital,
clinic or FQHC;
(5) to the extent
not covered by Paragraphs (3) and (4) of Subsection D of 8.321.2.9 NMAC above,
an "Indian Health Care Provider (IHCP)" defined in 42 Code of Federal
Regulations §438.14(a).
(6) a
children, youth and families department (CYFD) facility;
(7) a hospital and its outpatient
facility;
(8) a core service agency
(CSA);
(9) a CareLink NM health
home (CLNM HH);
(10) a crisis
triage center licensed by the department of health (DOH);
(11) a behavioral health agency
(BHA);
(12) an opioid treatment
program in a methadone clinic;
(13)
a political subdivision of the state of New Mexico; and
(14) a crisis services community provider as
a BHA.
(15) a school based health
center with behavioral health supervisory certification.
E. A behavioral health service rendered by a
licensed practitioner listed in Paragraph (2) of Subsection E of 8.321.2.9 NMAC
whose scope of licensure does not allow him or her to practice independently or
a non-licensed practitioner listed in Paragraph (3) of Subsection E of
8.321.2.9 NMAC is covered to the same extent as if rendered by a practitioner
licensed for independent practice, when the supervisory requirements are met
consistent with the practitioner's licensing board within his or her scope of
practice and the service is provided through and billed by one of the
provider's agencies listed in numbers one through nine of Subsection D of
8.321.2.9 NMAC, when the agency has a behavioral health services division
(BHSD) supervisory certificate, and Paragraphs (10) through (15) of Subsection
D of 8.321.2.9 NMAC. All services must be delivered according to the medicaid
regulation and current version of the behavioral health policy and billing
manual. If the service is an evaluation, assessment, or therapy service
rendered by the practitioner and supervised by an independently licensed
practitioner, the independently licensed practitioner's practice board must
specifically allow him or her to supervise the non-independent practitioner.
(1) Specialized behavioral health services,
other than evaluation, assessment, or therapy services, may have specific
rendering practitioner requirements which are detailed in each behavioral
health services section of 8.321.2.9 NMAC.
(2) The non-independently licensed rendering
practitioner with an active license which is not provisional or temporary must
be one of the following:
(a) a licensed master
of social work (LMSW) licensed by RLD's board of social work
examiners;
(b) a licensed mental
health counselor (LMHC) licensed by RLD's counseling and therapy practice
board;
(c) a licensed professional
mental health counselor (LPC) licensed by RLD's examiner board;
(d) a licensed associate marriage and family
therapist (LAMFT) licensed by RLD's examiner board;
(e) a psychologist associate licensed by the
RLD's psychologist examiners board;
(f) a licensed substance abuse associate
(LSAA) licensed by RLD's counseling and therapy practice board will be eligible
for reimbursement aligned with each tier level of designated scope of practice
determined by the board;
(g) a
registered nurse (RN) licensed by the New Mexico board of nursing under the
supervision of a certified nurse practitioner, clinical nurse specialist or
physician; or
(h) a licensed
physician assistant certified by the state of New Mexico if supervised by a
behavioral health physician or DO licensed by RLD's examiner board.
(3) Non-licensed practitioners
must be one of the following:
(a) a master's
level behavioral health intern;
(b)
a psychology intern including psychology practicum students, pre-doctoral
internship;
(c) a pre-licensure
psychology post doctorate student;
(d) a certified peer support
worker;
(e) a certified family peer
support worker; or
(f) a
provisional or temporarily licensed masters level behavioral health
professional.
(4) The
rendering practitioner must be enrolled as a MAD provider.
F. An eligible recipient under 21 years of
age may be identified through a tot to teen health check, self-referral,
referral from an agency (such as a public school, child care provider or other
practitioner) when he or she is experiencing behavioral health
concerns.
G. Either as a separate
service or a component of a treatment plan or a bundled service, the following
services are not MAD covered benefits:
(1)
hypnotherapy;
(2)
biofeedback;
(3) conditions that do
not meet the standard of medical necessity as defined in NMAC MAD
rules;
(4) educational or
vocational services related to traditional academic subjects or vocational
training;
(5) experimental or
investigational procedures, technologies or non-drug therapies and related
services;
(6) activity therapy,
group activities and other services which are primarily recreational or
diversional in nature;
(7)
electroconvulsive therapy;
(8)
services provided by a behavioral health practitioner who is not in compliance
with the statutes, regulations, rules or renders services outside his or her
scope of practice;
(9) treatment of
intellectual disabilities alone;
(10) services not considered medically
necessary for the condition of the eligible recipient;
(11) services for which prior authorization
is required but was not obtained; and
(12) milieu therapy.
H. All behavioral health services must meet
with the current MAD definition of medical necessity found in 8.302.1 NMAC.
Performance of a MAD behavioral health service cannot be delegated to a
provider or practitioner not licensed for independent practice except as
specified within this rule, within his or her practice board's scope and
practice and in accordance with applicable federal, state, and local statutes,
laws and rules. When a service is performed by a supervised practitioner, the
supervision of the service cannot be billed separately or additionally. Other
than agencies as allowed in Subsections D and E of 8.321.2.9 NMAC, a behavioral
health provider cannot himself or herself as a rendering provider bill for a
service for which he or she was providing supervision and the service was in
part or wholly performed by a different individual. Behavioral health services
are reimbursed as follows, except when otherwise described within a particular
specialized service's reimbursement section.
(1) Once enrolled, a provider receives
instructions on how to access documentation, billing, and claims processing
information. Reimbursement is made to a provider for covered services at the
lesser of the following:
(a) the MAD fee
schedule for the specific service or procedure; or
(b) the provider's billed charge. The
provider's billed charge must be its usual and customary charge for services
("usual and customary charge" refers to the amount that the individual provider
charges the general public in the majority of cases for a specific procedure or
service).
(2)
Reimbursement is made for an Indian health service (IHS) agency, a PL 93-638
tribal health facility, a federally qualified health center (FQHC), any other
"Indian Health Care Provider (IHCP)" as defined in 42 Code of Federal
Regulations §438.14(a), rural health clinic, or hospital-based rural
health clinic by following its federal guidelines and special provisions as
detailed in 8.310.4 and 8.310.12 NMAC.
I. All behavioral health services are subject
to utilization review for medical necessity and program compliance. Reviews can
be performed before services are furnished, after service is furnished but
before a payment is made, or after the payment is made; see 8.310.2 NMAC. The
provider must contact HSD or its authorized agents to request UR instructions.
It is the provider's and practitioner's responsibility to access these
instructions or ask for paper copies to be provided, to understand the
information provided, to comply with the requirements, and to obtain answers to
questions not covered by these materials. When services are billed to and paid
by a coordinated services contractor authorized by HSD, the provider must
follow that contractor's instructions for authorization of services. A
specialized behavioral health service may have additional prior authorization
requirements listed in that service's prior authorization subsection. All prior
authorization procedures must follow federal parity law.
J. For an eligible recipient to access
behavioral health services, a practitioner must complete a diagnostic
evaluation, progress and treatment notes and teaming notes, if indicated.
Exceptions to this whereby a treatment or set of treatments may be performed
before a diagnostic evaluation has been done, utilizing a provisional diagnosis
based on screening results are outlined in
8.321.2.14,
8.321.2.18
and
8.321.2.34
NMAC and in the behavioral health (BH) policy and billing manual. For a limited
set of treatments, (i.e. four or less), no treatment plan is required. All
documentation must be signed, dated and placed in the eligible recipient's
file. All documentation must be made available for review by HSD or its
designees in the eligible recipient's file (see the BH policy and billing
manual for specific instructions).
K. For recipients meeting the NM state
definition of serious mental illness (SMI) for adults or severe emotional
disturbances (SED) for recipients under 18 years of age or a substance use
disorder (SUD) for any age, a comprehensive assessment or diagnostic evaluation
and service plan must be completed (see the BH policy and billing manual for
specific instructions).
(1) Comprehensive
assessment and service plan can only be billed by the agencies listed in
Subsection D of 8.321.2.9 NMAC.
(2)
Behavioral health service plans can be developed by individuals employed by the
agency who have Health Insurance Portability and Accountability Act (HIPAA)
training, are working within their scope of practice, and are working under the
supervision of the rendering provider who must be a NM independently licensed
clinician.
(3) A comprehensive
assessment and service plan cannot be billed if care coordination is being
billed through bundled service packages such as case rates, value based
purchasing agreements, high fidelity wraparound or CareLink NM (CLNM) health
homes.
L. For
out-patient, non-residential recipients meeting the NM state definition of
serious mental illness (SMI) for adults or severe emotional disturbance (SED)
for recipients under 18 years of age or a moderate to severe substance use
disorder (SUD) for any age, where multiple provider disciplines are required
and engaged either for co-occurring conditions, or other social determinants of
health, an update to the service plan may be made using interdisciplinary
teaming. MAD covers service plan updates through the participation of
interdisciplinary teams.
(1) Coverage, purpose
and frequency of interdisciplinary team meetings:
(a) provides the central learning,
decision-making, and service integrating elements that weave practice functions
together into a coherent effort for helping a recipient meet needs and achieve
life goals; and
(b) covered team
meetings resulting in service plan changes or updates are limited to an annual
review, when recipient conditions change, or at critical decision points in the
recipient's progress to recovery.
(2) The team consists of:
(a) a lead agency, which must be one of the
agencies listed in Subsection D of 8.321.2.9 NMAC. This agency has a designated
and qualified team lead who prepares team members, convenes and organizes
meetings, facilitates the team decision-making process, and follows up on
commitments made;
(b) a
participating provider that is a MAD enrolled provider that is either already
treating the recipient or is new to the case and has the expertise pertinent to
the needs of the individual. This provider may practice within the same agency
but in a differing discipline, or outside of the lead agency;
(c) other participating providers not
enrolled with MAD, other subject matter experts, and relevant family and
natural supports may be part of the team, but are not reimbursed through MAD;
and
(d) the recipient, who is the
subject of this service plan update, must be a participating member of every
teaming meeting.
(3)
Reimbursement:
(a) only the team lead and two
other MAD enrolled participating providers or agencies may bill for the
interdisciplinary team update. When more than three MAD enrolled providers are
engaged within the session, the team decides who will bill based on the level
of effort or change within their own discipline.
(b) when the team lead and only one other
provider meet to update the service plan, the definition of teaming is not met
and the service plan update may not be billed using the interdisciplinary
teaming codes.
(c) the six elements
of teaming may be performed by using a variety of media (with the person's
knowledge and consent) e.g., texting members to update them on an emergent
event; using email communications to ask or answer questions; sharing
assessments, plans and reports; conducting conference calls via telephone;
using telehealth platforms conferences; and, conducting face-to-face meetings
with the person present when key decisions are made. Only the last element,
that is, conducting the final face-to-face meeting with the recipient present
when key decisions that result in the updates to the service plan, is a
billable event.
(d) when the
service plan updates to the original plan, that was developed within the
comprehensive assessment, are developed using the interdisciplinary teaming
model described in the BH policy and billing manual, service codes specific for
interdisciplinary teaming may be billed. If the teaming model is not used, only
the standard codes for updating the service plan can be billed. An update to
the service plan using a teaming method approach and an update to the service
plan not using the teaming method approach, cannot both be billed.
(e) billing instructions are found in the BH
policy and billing manual.
M. For recipients with behavioral health
diagnoses and other co-occurring conditions, or other social determinants of
health meeting medical necessity, and for whom multiple provider disciplines
are engaged, MAD covers service plan development and one subsequent update per
year for an interdisciplinary team.
(1) The
team consists of:
(a) a lead MAD enrolled
provider that has primary responsibility for coordinating the interdisciplinary
team, convenes and organizes meetings, facilitates the team decision-making
process, and follows up on commitments made;
(b) a participating MAD enrolled provider
from a different discipline;
(c)
other participating providers not enrolled with MAD, other subject matter
experts, and relevant family and natural supports may be part of the team, but
are not reimbursed through MAD; and
(d) the recipient, who is the subject of this
service plan development and update, must be a participating member of each
team meeting.
(2)
Reimbursement:
(a) only the team lead and one
other MAD enrolled participating provider may bill for a single session. When
more than two MAD enrolled providers are engaged with the session, the team
decides who will bill based on the level of effort or change within their own
discipline;
(b) this service plan
development and subsequent update to the original plan can only be billed twice
within one year; and
(c) billing
instructions are found in the BH policy and billing manual.
N. All specialized
behavioral health services should be delivered in the least restrictive
setting. Least restrictive settings will differ between services and
facilities, and are generally defined as a physical setting which places the
least restraint on the client's freedom of movement and opportunity for
independence and enables an individual to function with as much choice and
self-direction as safely appropriate. In addition, access to or receipt of one
service may not be contingent on requiring an individual to obtain or utilize
any other service; for example, a housing service may not require a treatment
component, nor may an outpatient treatment service require participation in
housing. Multiple services may be encouraged, under appropriate circumstances,
but may not be required.
