New Mexico Administrative Code
Title 8 - SOCIAL SERVICES
Chapter 325 - SPECIALTY SERVICES
Part 10 - EMERGENCY MEDICAL SERVICES FOR NON-CITIZENS
Section 8.325.10.16 - UTILIZATION REVIEW
Current through Register Vol. 35, No. 18, September 24, 2024
Claims for services to a recipient who is a non-citizen are reviewed by MAD or its designee before payment to determine if the circumstances warrant coverage.
A. Eligibility determination: A non-citizen recipient who requests MAD coverage for services must meet specific categorical eligibility requirements. Eligibility determinations by local county ISD offices must be made before the review for medical necessity.
B. Reconsideration: A provider and the non-citizen are given notice of the denial when the EMSA emergency criteria are not met. A non-citizen recipient can request a re-review and reconsideration of denied coverage of the service. See 8.350.2 NMAC, Reconsideration of Utilization Review Decisions. A non-citizen recipient can also request a hearing. See 8.52.2 NMAC, Recipient Hearings.