New Mexico Administrative Code
Title 8 - SOCIAL SERVICES
Chapter 324 - ADJUNCT SERVICES
Part 7 - TRANSPORTATION SERVICES AND LODGING
Section 8.324.7.15 - PRIOR AUTHORIZATION AND UTILIZATION REVIEW
Current through Register Vol. 35, No. 18, September 24, 2024
All MAD services are subject to utilization review (UR) for medical necessity and program compliance. Reviews can be performed before services are furnished, after services are furnished, and before payment is made or after payment is made. See 8.302.5 NMAC. The provider must contact HSD or its authorized agents to request UR instructions. It is the provider's responsibility to access these instructions or request hard copies to be provided, to understand the information, 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 MAD fee-for-service coordinated services contractor, the provider must follow that contractor's instructions for authorization of services.
A. Prior authorization: Certain procedures or services may require prior authorization from MAD or its designee. Services for which prior authorization is received remain subject to UR at any time during the payment process.
B. Referrals for travel outside the home community:
C. Eligibility determination: Prior authorization does not guarantee that individuals are eligible for MAD services. Providers must verify that an individual is eligible for MAD services at the time services are furnished and determine if the MAP eligible recipient has other health insurance.