New Mexico Administrative Code
Title 8 - SOCIAL SERVICES
Chapter 325 - SPECIALTY SERVICES
Part 8 - REHABILITATION SERVICE PROVIDERS
Section 8.325.8.15 - REIMBURSEMENT

Universal Citation: 8 NM Admin Code 8.325.8.15

Current through Register Vol. 35, No. 18, September 24, 2024

Outpatient rehabilitation providers must submit claims for reimbursement on the HCFA-1500 or UB-92 claim form or their successor, as appropriate for the provider. See 8.302.2 NMAC, Billing for Medicaid Services. Once enrolled, providers receive instructions on documentation, billing and claims processing.

A. Reimbursement for outpatient hospital rehabilitation medical services: For services reimbursed under the Title XVIII (medicare) allowable cost methodology, medicaid reduces the medicare allowable costs by three percent (3%). The interim rate of payment is seventy-seven percent (77%) of billed charges. Medicaid reimbursement does not exceed reasonable costs as defined by medicare. See 8.311.2 NMAC, Hospital Services.

B. Reimbursement for home health agency rehabilitation: See Section MAD-768, Home Health Services.

C. Reimbursement for independent physical therapists, independent occupational therapists and rehabilitation centers:

(1) Reimbursement to providers is made at the lesser of the following:
(a) the provider's billed charge; or

(b) the MAD fee schedule for the specific service or procedure.

(2) The provider's billed charge must be their usual and customary charge for services.

(3) "Usual and customary charge" refers to the amount which the individual provider charges the general public in the majority of cases for a specific procedure or service.

(4) Medicaid does not pay a professional component amount to a physical, occupational, or speech therapist if the therapy is performed in a hospital setting. Medicaid reimburses the institutional provider for all components of the service.

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